A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Inability to maintain employment

Reluctance to discard worthless objects

Avoidance of interpersonal relationships

Intense efforts to avoid abandonment

Answer and Explanation

The Correct Answer is D

Choice A reason:
The statement "Inability to maintain employment" is not a primary characteristic of borderline personality disorder (BPD). While individuals with BPD may struggle with maintaining employment due to emotional instability and interpersonal difficulties, this is not a defining feature of the disorder.

Choice B reason:
The statement "Reluctance to discard worthless objects" is more indicative of hoarding disorder, not BPD. Hoarding disorder involves persistent difficulty discarding or parting with possessions, regardless of their actual value.

Choice C reason:
The statement "Avoidance of interpersonal relationships" is more characteristic of avoidant personality disorder. Individuals with BPD often have intense and unstable relationships rather than avoiding them.

Choice D reason:
The statement "Intense efforts to avoid abandonment" is the correct response. A hallmark of BPD is the fear of abandonment and frantic efforts to avoid real or imagined abandonment. This can lead to unstable relationships and emotional distress.

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Correct Answer is B

Explanation

Choice A reason:
The statement "Identify when the client engages in splitting behaviors" is not appropriate for schizoid personality disorder. Splitting behaviors are more commonly associated with borderline personality disorder, where individuals may view others as all good or all bad. Schizoid personality disorder is characterized by a preference for solitary activities and emotional detachment.

Choice B reason:
The statement "Give the client a choice of solitary activities" is the correct response. Individuals with schizoid personality disorder often prefer solitary activities and may feel more comfortable engaging in them. Providing options for solitary activities respects their preferences and helps them feel more at ease in the care environment.

Choice C reason:
The statement "Assist the client in identifying sources of anger" is not typically relevant for schizoid personality disorder. These individuals often appear emotionally detached and may not express anger or other strong emotions openly. This intervention is more suited for personality disorders where emotional dysregulation is a primary concern.

Choice D reason:
The statement "Set limits on the client's need for constant social contact with others" is not applicable. Clients with schizoid personality disorder usually do not seek constant social contact; instead, they prefer to be alone and avoid social interactions. Setting limits on social contact is unnecessary and does not address their primary needs.

A. Repeat the dose in 15 minutes if the client is still anxious. B. Initiate fall precautions for the client. C. Instruct the client to expect ringing in the ears. D. Place the client in restraints for 1 hour.

Correct Answer is B

Explanation

Choice A reason:
The statement "Repeat the dose in 15 minutes if the client is still anxious" is not appropriate. Lorazepam is a benzodiazepine that can cause significant sedation and central nervous system depression. Repeating the dose too soon can increase the risk of severe sedation, respiratory depression, and other adverse effects.

Choice B reason:
The statement "Initiate fall precautions for the client" is the correct response. Lorazepam can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls, especially in older adults. Implementing fall precautions is essential to ensure the client's safety.

Choice C reason:
The statement "Instruct the client to expect ringing in the ears" is incorrect. Tinnitus (ringing in the ears) is not a common side effect of lorazepam. Common side effects include drowsiness, dizziness, and muscle weakness.

Choice D reason:
The statement "Place the client in restraints for 1 hour" is inappropriate. Restraints should only be used as a last resort when the client poses a danger to themselves or others and when less restrictive measures have failed.

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Neurologic:	Fatigue after being awake a few hours, feels “restless”. Difficulty concentrating on work and other activities. Difficulty falling asleep and wakes up “after a few hours". Worried about work and family needs.
Musculoskeletal:	Reports muscles feel tight and achy. Ambulates without assistance. Moves all four extremities independently.
Gastrointestinal:	Bowel sounds distant, present x four quadrants. Abdomen soft and nondistended, bladder slightly palpable.
Cardiovascular:	Apical 92/min and regular; peripheral pulses present bilaterally. Absence of lower extremity edema.
Respiratory:	Breath sounds present bilaterally. Occasional dry cough.

A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

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