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A nurse is caring for a client who has borderline personality disorder (BPD).

Check the 6 assessment findings that require immediate follow-up:.

Financial situation.

Increased use of mood-altering substances.

Sexual behaviors.

Hepatitis Viral Study (HAA) results.

BUN level.

Hgb level.

Sodium level.

Being admitted frequently

Recent loss of a parent

Answer and Explanation

Correct Answer : A,B,C,D,G,I

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Correct Answer is C

Explanation

Choice A rationale:

Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.

Choice B rationale:

Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.

Choice C rationale:

Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.

Choice D rationale:

Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.

A. Place the client on 12-hour observation. B. Remove harmful objects from the client's room. C. Encourage visitors for the client at any time. D. Encourage visitors to bring items to the client.

Correct Answer is B

Explanation

Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.

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A nurse is caring for a client who has borderline personality disorder (BPD). Check the 6 assessment findings that require immediate follow-up:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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A nurse is caring for a client who has borderline personality disorder (BPD).

Check the 6 assessment findings that require immediate follow-up:.