A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

The client has a history of bulimia nervosa.

The client has a parent who has dependent personality disorder.

The client has borderline personality disorder.

The client recently received a promotion at work.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.

Choice B rationale:

Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.

Choice C rationale:

Borderline personality disorder is strongly associated with self-harm behaviors.

Choice D rationale:

Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.

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Correct Answer is A

Explanation

Choice A rationale:

Twisting tongue movements are a common symptom of tardive dyskinesia (TD), a side effect of long-term use of antipsychotic medications like fluphenazine.

Choice B rationale:

Shuffling gait is more commonly associated with Parkinson’s disease and certain antipsychotic medications can cause Parkinson-like symptoms, but it is not a characteristic of TD2.

Choice C rationale:

Sudden onset of high fever is not associated with TD. It could be a sign of a serious condition like neuroleptic malignant syndrome, which requires immediate medical attention.

Choice D rationale:

Constant tapping of feet when sitting could be a sign of restlessness or akathisia, another potential side effect of antipsychotic medications, but it is not a specific sign of TD2.

A. Joining a group discussion about a local election. B. Watching a video with a group in the day room. C. Walking with the nurse in the courtyard. D. Participating in a basketball game in the gym.

Correct Answer is C

Explanation

Choice A rationale:

Group discussions about local elections can be stimulating and may exacerbate the client’s manic symptoms.

Choice B rationale:

Watching a video with a group in the day room may not provide enough engagement for a client in a manic phase.

Choice C rationale:

Walking with the nurse in the courtyard provides physical activity and one-on-one interaction, which can help manage energy levels and provide a calming influence.

Choice D rationale:

Participating in a basketball game in the gym could overstimulate the client and potentially lead to injury.

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A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

Correct Answer is A

Explanation

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

Correct Answer is C

Explanation

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things.”. Which of the following responses by the nurse is appropriate?.

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A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.).

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

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

A nurse is reviewing the medical record of a client who performs self-injury.

Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?