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) Tinnitus: While tinnitus can be concerning, it is not a classic side effect of digoxin. It may indicate other issues such as hearing problems or medication interactions, but it does not typically warrant immediate communication with the healthcare provider in the context of digoxin use.

B) Constipation: Although constipation can occur in some patients taking digoxin, it is generally not considered a critical side effect that requires urgent attention. Patients are encouraged to manage this symptom through dietary changes or over-the-counter remedies unless it becomes severe.

C) Visual disturbances: Experiencing visual disturbances, such as seeing halos around lights or blurred vision, can be a sign of digoxin toxicity. Since these symptoms can indicate an elevated level of the drug in the bloodstream, it is crucial for the patient to contact their healthcare provider promptly to assess the situation and prevent further complications.

D) Vertigo: While vertigo can occur in various medical conditions and may be a side effect of other medications, it is not specifically linked to digoxin. If a patient experiences vertigo, they should monitor it but are not necessarily required to contact their healthcare provider immediately unless it is severe or persistent.

A. should continue to read the labels of foods I select in the grocery store." B. When get out of bed in the morning. I should first sit for a few minutes and then stand." C. will be able to stop my anti-hypertensive medication when my blood pressure is normal." D. "Keeping my blood pressure under control reduces my risk for a heart attack."

Correct Answer is C

Explanation

A. "I should continue to read the labels of foods I select in the grocery store.": This statement is appropriate as reading labels helps the client avoid high sodium and unhealthy fats, which can negatively impact blood pressure.

B. "When I get out of bed in the morning, I should first sit for a few minutes and then stand.": This statement reflects a good understanding of managing potential orthostatic hypotension, which can occur with antihypertensive medications. It indicates awareness of the need to rise slowly to prevent dizziness.

C. "I will be able to stop my anti-hypertensive medication when my blood pressure is normal.": This statement indicates a need for clarification. Many patients believe that once their blood pressure is normal, they can discontinue medication, but hypertension is often a chronic condition that requires ongoing management to maintain blood pressure control.

D. "Keeping my blood pressure under control reduces my risk for a heart attack.": This statement is accurate and demonstrates an understanding of the importance of hypertension management in reducing cardiovascular risk.

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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 should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?

Correct Answer is C

Explanation

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is C

Explanation

The nurse calculates that 0.74 mi of filgrastim must be administered to a client subcutaneously. The client weights 165 lbs. What length and gauge of needle is best to administer this medication?

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