A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest. The nurse should identify that the client is at risk for which of the following?
Illusion
Hallucination
Attention-seeking behavior
Self-mutilation
The Correct Answer is D
A. Illusion: An illusion is a misinterpretation or misperception of a real external stimulus. It involves a distortion of sensory perception, but the client's statement does not suggest a misperception of reality.
B. Hallucination: A hallucination is a sensory perception in the absence of any external stimulus. It involves experiencing something that is not present in reality. The client's statement does not indicate experiencing a sensory perception that is not real.
C. Attention-seeking behavior: While the client's statement may draw attention to their distress, it is important not to dismiss it as merely attention-seeking behavior. The client's request for the pen to alleviate emotional pain suggests a deeper psychological issue and a genuine risk for self-harm.
D. Self-mutilation: Self-mutilation refers to intentional self-inflicted injury or harm to one's body tissue without the intent to die. The client's statement about using the pen to cut the pain out of their chest indicates a clear risk for self-mutilation.
Nursing Test Bank
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 A
Explanation
A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.
B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.
C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.
D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.
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