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

Explanation

Choice A reason: Serotonin deficiency is a well-known risk factor for major depressive disorder. Serotonin is a neurotransmitter that plays a crucial role in mood regulation, and its deficiency can lead to symptoms of depression. This is why many antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), aim to increase serotonin levels in the brain.

Choice B reason: Acute bronchitis is a respiratory condition that involves inflammation of the bronchial tubes. While it can cause significant discomfort and health issues, it is not directly linked to major depressive disorder. However, chronic illnesses can sometimes contribute to depressive symptoms due to the ongoing stress and physical limitations they impose.

Choice C reason: Elevated calcium levels, or hypercalcemia, can cause a variety of symptoms, including fatigue, confusion, and depression-like symptoms. However, it is not a primary risk factor for major depressive disorder. Hypercalcemia is usually related to other underlying conditions such as hyperparathyroidism or certain cancers.

Choice D reason: Being an only child is not considered a risk factor for major depressive disorder. While family dynamics and social relationships can influence mental health, there is no direct evidence linking being an only child to an increased risk of developing major depressive disorder.

A. “ECT is contraindicated in clients who have psychotic symptoms.” B. “ECT is delivered through electrodes attached to the head.” C. “ECT cannot be administered to clients who have suicidal ideation.” D. “ECT is conducted under regional anesthesia.”

Correct Answer is B

Explanation

Choice A reason:

ECT is not contraindicated in clients with psychotic symptoms. In fact, it is often used to treat severe depression with psychotic features, as well as other conditions such as mania and catatonia. ECT can be highly effective in reducing symptoms of psychosis when other treatments have failed.

Choice B reason:

ECT is delivered through electrodes attached to the head. During the procedure, a small amount of electrical current is passed through the brain to induce a controlled seizure, which can help alleviate symptoms of severe depression and other mental health conditions.

Choice C reason:

ECT can be administered to clients with suicidal ideation. It is often considered when rapid symptom relief is needed, such as in cases of severe depression with a high risk of suicide. ECT can provide quick and significant improvement in mood and functioning.

Choice D reason:

ECT is conducted under general anesthesia, not regional anesthesia. General anesthesia ensures that the client is unconscious and does not feel pain during the procedure. Muscle relaxants are also administered to prevent physical convulsions during the induced seizure.

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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 reviewing the medical record of a newly admitted client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for this condition?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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