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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Correct Answer is C

Explanation

A. Bone marrow aspiration study: While this test can provide information about the bone marrow's ability to produce red blood cells, it is not typically the first diagnostic test used to detect the cause of chronic iron deficiency anemia.

B. Vitamin B2 level: This test measures riboflavin levels, which are not related to iron deficiency anemia. Vitamin B12 or folate levels are more relevant in differentiating types of anemia.

C. Stool for occult blood: This test is commonly used to detect hidden blood in the stool, which can indicate gastrointestinal bleeding—a frequent cause of chronic iron deficiency anemia. Identifying blood loss in the GI tract is crucial for diagnosing the underlying issue.

D. Schelling's test: This test is used to determine the absorption of vitamin B12 and is not
applicable to iron deficiency anemia.

A. Second Intercostal space right of sternum B. Fourth intercostal space, left mid-clavicular line C. Third intercostal space, left of sternum D. Second intercostal space left of sternum

Correct Answer is A

Explanation

A) Second intercostal space right of sternum: This is the correct location for auscultating an aortic murmur. The aortic area is best heard at the second intercostal space on the right side of the sternum, where the sound of blood flow through the aortic valve is most prominent.

B) Fourth intercostal space, left mid-clavicular line: This location is typically associated with the mitral valve area, not the aortic area. While important for other heart sounds, it does not correspond to where an aortic murmur would be heard loudest.

C) Third intercostal space, left of sternum: This area is generally associated with the pulmonic area, not the aorta. Murmurs from the aortic valve would not be best heard here.

D) Second intercostal space left of sternum: This location is associated with the pulmonic area as well. An aortic murmur would not be best auscultated here, making this option incorrect for identifying an aortic murmur specifically.

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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

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?

Correct Answer is C

Explanation

The nurse auscultates a heart murmur on a client with cardiovascular disease. At which anatomic landmark will an aortic murmur be heard the loudest?

Correct Answer is A

Explanation

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?

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

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The nurse is reviewing the past medical history of a group of clients. Which client would the nurse suspect as having folic acid deficiency? The: