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 C

Explanation

A. Your blood pressure reflects how strong your heart muscle contracts: This statement oversimplifies the complexities of blood pressure and doesn't directly address the client's misunderstanding about the implications of hypertension.

B. "If you feel good your medication is working properly": While this may be true, it fails to convey the importance of monitoring blood pressure, regardless of symptoms. It might lead the client to believe that feeling well means there are no health concerns.

C. "Even if you are feeling good, damage can occur to your heart and kidneys": This response is the most appropriate as it emphasizes that hypertension can cause silent damage over time, even in the absence of symptoms. It educates the client about the potential long-term consequences of uncontrolled hypertension.

D. "Have you told your doctor that you are feeling good?": While it encourages communication, it does not provide useful information or address the client’s misconceptions about hypertension and its risks.

Correct Answer is ["116"]

Explanation

To calculate the infusion rate, we'll follow these steps:

Determine the total volume to be administered:

8 mL (drawn from the vial) + 50 mL (dilution with NSS) = 58 mL

Calculate the infusion rate:

58 mL ÷ 30 minutes = 1.93 mL/minute

Convert mL/minute to mL/hour:

1.93 mL/minute × 60 minutes/hour = 116 mL/hour

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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 client diagnosed with primary hypertension states, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate response?

Correct Answer is C

Explanation

Correct Answer is ["116"]

Explanation

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