A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

The client will verbalize an improved mood.

The client will report a decrease in hallucinations.

The client will attend to personal hygiene.

The client will communicate needs.

Answer and Explanation

The Correct Answer is D

Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.

Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.

Choice C reason: Encouraging personal hygiene supports general self-care but does not target the specific therapeutic goals for borderline personality disorder, which center on interpersonal effectiveness and emotion regulation.

Choice D reason: Teaching the client to articulate needs directly builds assertive communication and interpersonal effectiveness—core competencies in dialectical behavior therapy that reduce maladaptive behaviors and improve relationship stability.

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Correct Answer is A

Explanation

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

A. Instruct the client to expect ringing in the ears. B. Place the client in restraints for 1 hour. C. Initiate fall precautions for the client. D. Repeat the dose in 15 minutes if the client is still anxious.

Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

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A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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