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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Setting limits is not typically the primary behavioral management technique for clients with delirium. Delirium is an acute and often reversible state of confusion that requires addressing the underlying medical cause. Management strategies for delirium focus on reorientation, ensuring safety, and treating any underlying conditions rather than setting behavioral limits.

Choice B reason: Clients with depression may benefit from supportive and empathetic interactions rather than strict behavioral limits. While structure and routine can be helpful, the primary approach for managing depression involves therapeutic communication, medication management, and cognitive-behavioral strategies rather than setting limits on behavior.

Choice C reason: Setting limits is an essential behavioral management technique for clients with antisocial personality disorder. Individuals with this disorder often exhibit manipulative, deceitful, and aggressive behaviors. Clear and consistent limits help establish boundaries and prevent the exploitation of others. This approach promotes accountability and helps manage inappropriate behaviors in a therapeutic setting.

Choice D reason: Generalized anxiety disorder is characterized by excessive and persistent worry. Behavioral management techniques for anxiety disorders typically include cognitive-behavioral therapy, relaxation techniques, and sometimes medication. Setting limits is not a primary intervention for managing anxiety; rather, the focus is on reducing anxiety symptoms through therapeutic strategies.

A. You will be given an opioid analgesic before the procedure. B. Expect to be confused several hours after the procedure. C. You cannot eat or drink for 24 hours before the procedure. D. A consent form is not required to have this procedure.

Correct Answer is B

Explanation

Choice A reason: Opioid analgesics are not typically given before electroconvulsive therapy (ECT). Instead, a general anesthetic and a muscle relaxant are administered to ensure the patient is asleep and to prevent muscle contractions during the procedure. The nurse should inform the client about the medications they will receive before ECT, but opioid analgesics are not usually part of the protocol.

Choice B reason: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.

Choice C reason: Clients are usually instructed to fast (not eat or drink) for a shorter period, typically 6-8 hours, before the procedure to reduce the risk of aspiration during anesthesia. Informing the client to fast for 24 hours is excessive and not in line with standard preoperative fasting guidelines.

Choice D reason: A consent form is required before undergoing ECT. Informed consent is a critical component of the process, ensuring that the client understands the procedure, its benefits, risks, and potential side effects. The nurse must reinforce the importance of obtaining and signing the consent form before proceeding with ECT.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for a nicotine transdermal system. Which of the following statements should the nurse make?

A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?

A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?

A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says, "I heard that Mr. Smith was admitted for a suicide attempt." Which of the following responses should the charge nurse make?

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?

A nurse is caring for a client who has a phobia of elevators. Which of the following behavioral strategies should the nurse plan to use to decrease anxiety?

A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?

A nurse is collecting data from a client who has been admitted with manifestations of paranoia. Which of the following findings should the nurse identify as a risk factor for schizophrenia?