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 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.

A. Hallucinations B. Depression C. Delusions D. Catatonia E. Tinnitus

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.

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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

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

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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?