A patient with borderline personality disorder has cut her wrists while on the unit. Which of the following is NOT an appropriate nursing intervention?

Devoting extended 1:1 time with the client to vent about their feelings.

Asking the client to write down feelings prior to injury.

Maintaining a neutral tone when assessing the injury.

Helping the patient identify healthy ways to respond to negative emotions.

Answer and Explanation

The Correct Answer is A

A: Devoting extended 1:1 time with the client to vent about their feelings is not appropriate because it can reinforce the behavior by providing attention. It is important to provide support without reinforcing maladaptive behaviors.

B: Asking the client to write down feelings prior to injury is an appropriate intervention as it encourages the patient to express emotions in a non-harmful way.

C: Maintaining a neutral tone when assessing the injury is important to avoid reinforcing the behavior through emotional reactions.

D: Helping the patient identify healthy ways to respond to negative emotions is a key intervention in managing borderline personality disorder and preventing self-harm.

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Correct Answer is A

Explanation

A: Placing the difficulty in understanding on yourself by saying, “I’m having trouble following you,” is a therapeutic communication technique. It helps to reduce the patient’s anxiety and encourages them to clarify their thoughts without feeling judged. This approach fosters a supportive environment and can help the patient organize their thoughts better.

B: Letting the patient think you understand to minimize their anxiety is not an effective strategy. It can lead to further confusion and does not help the patient improve their communication. Honesty and clarity are important in therapeutic interactions.

C: Using reality testing to help the patient clarify their statements can be useful, but it may not be the best initial approach. It requires the patient to have some level of insight and ability to engage in reality testing, which may not be possible in severe cases of associative looseness.

D: Telling the patient they are not making any sense can be perceived as judgmental and may increase the patient’s anxiety and frustration. It is not a supportive or therapeutic approach and can hinder effective communication.

A. She rarely eats meals with the family; instead, she sneaks food up to her room. B. She is too tired to do chores around the house, which is unusual for her. C. I know she has been very anxious lately; her schoolwork has been challenging her. D. She will feel a lot better when she finds out if she was accepted to her first-choice college.

Correct Answer is A

Explanation

A: This statement suggests secretive eating behaviors, which are characteristic of bulimia. Individuals with bulimia often eat large amounts of food in secret and then engage in compensatory behaviors such as purging. The mother’s observation that her daughter sneaks food to her room aligns with this pattern.

B: While fatigue and a lack of energy can be associated with various conditions, including eating disorders, this statement is not specific enough to indicate bulimia. It could be related to many other factors such as stress, depression, or physical illness.

C: Anxiety and academic challenges are common among adolescents but do not specifically point to bulimia. While stress can contribute to eating disorders, this statement alone does not provide enough evidence to suggest bulimia.

D: This statement reflects a situational stressor related to college acceptance but does not indicate any eating disorder behaviors. It is more about the adolescent’s emotional state and future plans rather than current eating habits.

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A patient with borderline personality disorder has cut her wrists while on the unit. Which of the following is NOT an appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a person displaying associative looseness. Which of the following would be the best strategy for the nurse to respond to associative looseness?

Correct Answer is A

Explanation

A nurse is caring for an adolescent who fainted at school. When interviewing the family, which statement by the mother best aligns with the diagnosis of bulimia?

Correct Answer is A

Explanation

The following clients are waiting to be seen in the emergency department. Which client should the nurse assess first?

A patient with borderline personality disorder has cut her wrists while on the unit. Which of the following is NOT an appropriate nursing intervention?

A client diagnosed with a personality disorder states, “You are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 p.m.” This statement would be associated with which personality disorder?

The nurse is reviewing documentation after restraints were used. What item from the documentation should be removed?

A patient was placed in restraints after punching a staff member. Which statement by the patient requires the nurse’s immediate attention?

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A client with antisocial personality disorder has a history of responding to frustration by being verbally abusive. How would the nurse manage this behavior? Select all that apply.