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
The Correct Answer is C
A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.
B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.
C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.
D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.
B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.
C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.
D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.
A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.
B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.
C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.
D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.
Correct Answer is C
Explanation
A. These clients can receive packages after they are privately inspected by security: While security measures may be in place to ensure the safety and appropriateness of packages received by clients in a mental health facility, the ability to receive packages is not necessarily dependent on the client's involuntary admission status. Policies regarding package inspections may vary by facility and are not specific to involuntary admission status.
B. Involuntarily admitted clients can be considered for research studies, provided they give informed consent and the study meets ethical guidelines.
C. Clients who are involuntarily admitted retain their right to vote, provided they meet the usual eligibility requirements for voting. Their legal status regarding involuntary admission does not affect their voting rights.
D. Involuntarily admitted clients do have the right to refuse medications, unless a court order mandates treatment or an emergency situation exists where the client poses a danger to themselves or others.
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