A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Provide additional attention to the client.

Apply mechanical restraints before administering medication.

Obtain a verbal contract from the client.

Limit staff members who work with the client.

Answer and Explanation

The Correct Answer is C

Choice A reason: Providing additional attention to the client can sometimes reinforce negative behaviors in individuals with borderline personality disorder. It is important to balance attention with promoting independence and self-regulation.

Choice B reason: Applying mechanical restraints before administering medication is not a standard practice and can be considered unethical and harmful. Restraints should only be used as a last resort when there is an immediate risk of harm to the client or others.

Choice C reason: Obtaining a verbal contract from the client is a therapeutic intervention that can help manage self-mutilation risks. This contract involves the client agreeing to communicate with staff before engaging in self-harm, which can help in developing trust and promoting safety.

Choice D reason: Limiting staff members who work with the client can help provide consistency and stability, which is beneficial for individuals with borderline personality disorder. However, it is not the primary intervention for preventing self-mutilation.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.

Choice B reason:

Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.

Choice C reason:

Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.

Choice D reason:

Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.

Choice E reason:

Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.

A. “These clients can receive packages after they are privately inspected by security.” B. “These clients cannot be considered for a research study.” C. “These clients can vote in local and federal elections.” D. “These clients cannot refuse their prescribed antipsychotic medications.”

Correct Answer is C

Explanation

Choice A reason:

While clients may receive packages, this statement does not specifically address their rights. The focus should be on their fundamental rights and freedoms.

Choice B reason:

Clients who are involuntarily admitted can be considered for research studies, provided they give informed consent and the study is ethically approved.

Choice C reason:

Clients who are involuntarily admitted retain their right to vote in local and federal elections. This is a fundamental right that is not lost due to their admission status.

Choice D reason:

Clients who are involuntarily admitted still have the right to refuse medications, including antipsychotics, unless there is a court order or emergency situation that mandates treatment.

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A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A charge nurse is providing education to a group of newly licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses indicates understanding of the teaching?

Correct Answer is C

Explanation

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