A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

Notify child protective services.

Suggest the children live with other relatives.

Encourage the children to visit the psychiatric unit when the client is leaving.

Offer the client information about a support group for parents.

Answer and Explanation

The Correct Answer is D

A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.

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Correct Answer is C

Explanation

A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.

A. Engaging in extracurricular activities B. Loss of a job C. Financial stability D. Exercising caution in behavior

Correct Answer is B

Explanation

A. Engaging in extracurricular activities. Participating in extracurricular activities is generally associated with social support and positive mental health. Individuals involved in structured activities often have a sense of purpose and connection, which can be protective against suicide rather than a risk factor.
B. Loss of a job. Job loss is a significant risk factor for suicide due to its impact on financial stability, self-esteem, and emotional well-being. Unemployment can lead to feelings of hopelessness, social isolation, and increased stress, all of which contribute to a higher suicide risk.
C. Financial stability. Financial stability generally reduces stress and provides security, lowering the likelihood of suicidal ideation. While financial difficulties can be a risk factor, having stable finances is not associated with increased suicide risk.
D. Exercising caution in behavior. Practicing caution in behavior reflects awareness of potential dangers and a tendency to avoid reckless or impulsive actions. Individuals who take precautions in their daily lives are less likely to engage in high-risk behaviors that could lead to suicide.

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A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?