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

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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Correct Answer is B

Explanation

A. “ECT contraindicated in clients who have psychotic symptoms.”: This statement is incorrect. ECT can be used to treat various mental health conditions, including severe depression with psychotic features. It is not contraindicated solely based on the presence of psychotic symptoms.

B. "ECT is delivered through electrodes attached to the head.”: This statement is accurate. Electroconvulsive therapy (ECT) involves the delivery of electrical currents to the brain through electrodes placed on the scalp. These electrodes are positioned to target specific areas of the brain.

C. “ECT cannot be administered to clients who have suicide ideation”: This statement is incorrect. ECT can be considered as a treatment option for individuals with severe depression, including those with suicidal ideation or behavior. It can be effective in rapidly alleviating symptoms and reducing suicide risk in some cases.

D. “ECT is conducted under regional anesthesia.”: This statement is incorrect. Electroconvulsive therapy (ECT) is typically performed under general anesthesia to ensure the client's comfort and safety during the procedure. Regional anesthesia is not commonly used for ECT.

A. A client who is experiencing withdrawal from oxycodone. B. A client who is experiencing withdrawal from diazepam C. A client who has a low lithium level D. A client who has a low imipramine level

Correct Answer is B

Explanation

A. A client who is experiencing withdrawal from oxycodone: While withdrawal from opioids like oxycodone can cause various symptoms, including agitation, anxiety, and muscle aches, it's not typically associated with an increased risk of seizures.

B. A client who is experiencing withdrawal from diazepam: Withdrawal from benzodiazepines like diazepam can indeed increase the risk of seizures. Abrupt cessation of benzodiazepines after prolonged use can lead to withdrawal symptoms, including seizures. Therefore, seizure precautions would be appropriate for this client.

C. A client who has a low lithium level: Low lithium levels can potentially lead to lithium toxicity, which can cause various symptoms, but seizures are not commonly associated with low lithium levels. However, in severe cases of lithium toxicity, seizures can occur.

D. A client who has a low imipramine level: Imipramine is a tricyclic antidepressant (TCA). Low levels of TCAs are not typically associated with an increased risk of seizures. However, high levels of TCAs can be toxic and may lead to seizures.

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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 preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT) Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

Correct Answer is B

Explanation

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