A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

restrain the client to prevent self-harm

assist the client to identify the trigger situation and choose a coping strategy.

send the client to the crisis intervention unit for 23 hours of observation.

advise the client to take an anxiolytic to decrease their anxiety level.

Answer and Explanation

The Correct Answer is B

A. Restraining the client to prevent self-harm: While safety is a priority, physical restraint should be a last resort and not the first action taken in this scenario. It may escalate the situation and lead to feelings of loss of control.
B. Assist the client to identify the trigger situation and choose a coping strategy: This is the best initial intervention. Helping the client understand their triggers and encouraging the development of coping strategies can empower them and promote healthier responses to distress. This approach aligns with therapeutic practices that support emotional regulation.

C. Send the client to the crisis intervention unit for 23 hours of observation: While observation may be necessary if the client is at imminent risk of self-harm, it is essential first to explore the underlying issues and coping mechanisms. This action may be considered if the client remains a danger to themselves after initial interventions.

D. Advise the client to take an anxiolytic to decrease their anxiety level: Medications may help with anxiety, but this approach does not address the root of the problem or provide the client with skills to manage their distress. It is more beneficial to focus on therapeutic techniques first.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Administer the medications at different times to provide an even blood level: This option is inappropriate given the client's current heart rate. Both atenolol and diltiazem are cardiovascular medications that can further lower heart rate and potentially lead to bradycardia or other complications.

B. Assess the client's blood pressure and if the BP is normal, administer the medications: While it's important to assess blood pressure, both medications can further decrease heart rate. Given the current bradycardia (heart rate of 45 beats/min), administering either medication could exacerbate the issue.

C. Document the pulse rate and administer the medications as prescribed: This option is not appropriate. The pulse rate of 45 beats/minute is significantly below the normal range, and administering medications that can lower heart rate further could pose serious risks.

D. Withhold the medications and reassess the heart rate in 30 minutes: This is the best nursing action. Withholding the medications allows for further evaluation of the client's heart rate, and it ensures that the nurse can prevent potential adverse effects related to the bradycardia.

A. increase calcium in the diet. B. monitor weight on a weekly basis. C. obtain blood pressure checks twice a year. D. have yearly eye examinations.

Correct Answer is B

Explanation

A. Increase calcium in the diet: While calcium is important, it's not the most critical aspect in managing hypertension compared to weight management.

B. Monitor weight on a weekly basis: Weight management is crucial for clients with hypertension, as fluctuations can indicate changes in fluid retention or overall health. Regular monitoring can help in managing blood pressure.

C. Obtain blood pressure checks twice a year: This is insufficient for monitoring hypertension; more frequent checks are generally recommended.

D. Have yearly eye examinations: While important for overall health, it’s not as directly related to the management of hypertension as monitoring weight.

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A client with borderline personality disorder reports to the nurse that they anxious & wants to cut their thigh. The nurse should first:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled to receive atenolol 25 mg PO and diltiazem 60 mg PO at 0800. The nurse assesses the client's heart rate as 45 beats/minute and irregular. What is the best nursing action at this time?

Correct Answer is D

Explanation

The nurse who is providing instructions to a client with hypertension will stress that it is most important to:

Correct Answer is B

Explanation

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