A physician mentions to a nurse that a newly admitted client is impulsive. The nurse should assess for behavior characterized by:

postponing gratification to an appropriate time.

little time elapsed between thought and action.

adherence to a strict moral code.

manipulative, controlling strategies.

Answer and Explanation

The Correct Answer is B

B. Impulsive individuals tend to act quickly without fully considering the consequences of their actions. There is often little to no delay between the thought or impulse and the resulting behavior.
A. Individuals who are impulsive tend to have difficulty delaying gratification and may act on immediate impulses without considering long-term consequences.
C. Impulsivity is not necessarily related to moral behavior. While impulsive individuals may sometimes engage in behaviors that conflict with their moral code, impulsivity itself does not indicate adherence or lack thereof to a moral code.
D. Impulsivity is more about acting quickly without forethought rather than deliberately manipulating or controlling situations.

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Correct Answer is A

Explanation

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

A. advise the client to take an anxiolytic to decrease their anxiety level. B. restrain the client to prevent self-harm. C. assist the client to identify the trigger situation and choose a coping strategy. D. encourage the client use self-harm behaviors to release emotion.

Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

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A physician mentions to a nurse that a newly admitted client is impulsive. The nurse should assess for behavior characterized by:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

Correct Answer is A

Explanation

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

Correct Answer is C

Explanation

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

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