A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?
A client who has borderline personality disorder and acts impulsively
A client who has avoidant personality disorder and becomes anxious in social situations
A client who has dependent personality disorder and clings to nursing staff
A client who has histrionic personality disorder and seeks constant attention
The correct answer is: a) A client who has borderline personality disorder and acts impulsively
The Correct Answer is A
Choice A reason: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support from the healthcare team to manage and mitigate these risks effectively.
Choice B reason: While clients with avoidant personality disorder may experience significant anxiety in social situations, this typically does not pose an immediate threat to their physical safety. The primary concern with avoidant personality disorder is social isolation and the impact on their mental health and quality of life. Anxiety in social situations can be distressing, but it does not inherently lead to dangerous behaviors.
Choice C reason: Clients with dependent personality disorder often exhibit clingy and submissive behaviors, relying heavily on others for support and decision-making. While this can create challenges in managing boundaries and fostering independence, it is not typically associated with immediate safety risks. The focus of care for these clients is on building self-reliance and coping skills.
Choice D reason: Clients with histrionic personality disorder often seek constant attention and may display dramatic, exaggerated behaviors. While this can be disruptive and challenging in a therapeutic setting, it does not usually pose a direct threat to the client's safety. The primary concern is managing interpersonal dynamics and ensuring that the client's behaviors do not negatively impact the therapeutic environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Naltrexone is not designed to prevent alcohol withdrawal symptoms. It works by blocking the euphoric effects of alcohol and reducing cravings, but clients who stop drinking may still experience withdrawal symptoms. Proper medical management and support are necessary to address alcohol withdrawal.
Choice B reason: Naltrexone does not help clients gradually decrease alcohol intake. Instead, it is used to help maintain abstinence by reducing cravings and the reinforcing effects of alcohol. Clients typically need to stop drinking before starting naltrexone treatment.
Choice C reason: Ringing in the ears, or tinnitus, is not a common side effect of naltrexone or an expected reaction when consuming alcohol while on the medication. This statement indicates a misunderstanding of how naltrexone works and its potential side effects.
Choice D reason: This statement accurately reflects one of the primary effects of naltrexone. The medication helps reduce cravings for alcohol, making it easier for individuals to maintain abstinence and avoid relapse. By understanding this aspect of naltrexone, the client demonstrates a clear understanding of its purpose and use in alcohol dependence treatment.
Correct Answer is A
Explanation
Choice A reason: Hypokalemia, or low potassium levels in the blood, is a common finding in individuals with bulimia nervosa, especially those who engage in frequent vomiting or use laxatives. Purging behaviors can lead to significant electrolyte imbalances, including potassium depletion, which can cause muscle weakness, cramps, and cardiac arrhythmias. Monitoring potassium levels is crucial in managing the health of individuals with bulimia nervosa.
Choice B reason: Leukopenia, or a low white blood cell count, is not typically associated with bulimia nervosa. While malnutrition and other complications of eating disorders can affect the immune system, leukopenia is more commonly linked to conditions such as infections, autoimmune disorders, or certain medications.
Choice C reason: Decreased serum amylase is not a typical finding in bulimia nervosa. In fact, elevated serum amylase levels are more commonly observed due to the stress on the salivary glands from frequent vomiting. Hyperamylasemia can be an indicator of purging behaviors and should be monitored in individuals with bulimia nervosa.
Choice D reason: Hematuria, or the presence of blood in the urine, is not commonly associated with bulimia nervosa. While hematuria can result from various conditions, including urinary tract infections, kidney stones, or other renal issues, it is not a typical finding in individuals with bulimia nervosa.
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