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

Assist the client to identify the triggering situation and choose a coping strategy.

Send the client to the crisis intervention unit for 23 hours of observation.

Restrain the client to prevent self-harm.

Advise the client to take an anxiolytic to decrease their anxiety level.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Assist the client to identify the triggering situation and choose a coping strategy

This is the correct answer. Assisting the client to identify the triggering situation and choose a coping strategy is a therapeutic approach that empowers the client to understand and manage their emotions. This intervention helps the client develop skills to cope with distressing feelings and reduces the likelihood of self-harm. It is essential to address the underlying issues and provide support in a constructive manner.

Choice B Reason: Send the client to the crisis intervention unit for 23 hours of observation

While sending the client to a crisis intervention unit may be necessary in some cases, it is not the first step. Immediate therapeutic intervention to help the client understand and manage their emotions is crucial. Observation alone does not address the underlying issues or provide the client with coping mechanisms.

Choice C Reason: Restrain the client to prevent self-harm

Restraint should be a last resort and only used when there is an immediate risk of harm that cannot be managed through other means. It is important to first attempt less restrictive interventions that help the client manage their emotions and behaviors.

Choice D Reason: Advise the client to take an anxiolytic to decrease their anxiety level

While medication can be part of the treatment plan, it should not be the first intervention. Addressing the client’s immediate emotional needs and helping them develop coping strategies is crucial. Medication can be considered as part of a comprehensive treatment plan but should not replace therapeutic interventions.

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 B

Explanation

Choice A Reason: Insert a nasogastric tube

This choice is incorrect. Inserting a nasogastric tube is not the highest priority intervention for a client who has just received naloxone. While it may be necessary in some cases for other reasons, the immediate concern after naloxone administration is to ensure the client’s airway is open and they are breathing adequately. Naloxone reverses opioid effects, which can cause respiratory depression, so monitoring the airway and vital signs is crucial.

Choice B Reason: Monitor airway and vital signs

This choice is correct. The highest priority after administering naloxone is to monitor the client’s airway and vital signs. Naloxone can rapidly reverse opioid-induced respiratory depression, but its effects may wear off before the opioids are completely metabolized, leading to a risk of re-sedation and respiratory depression. Continuous monitoring ensures that any changes in the client’s condition are detected and managed promptly.

Choice C Reason: Insert an indwelling urinary catheter or monitor output

This choice is incorrect. While monitoring urine output can be important in assessing overall kidney function and fluid balance, it is not the highest priority immediately after naloxone administration. The primary concern is the client’s respiratory status and ensuring they maintain an open airway and adequate ventilation.

Choice D Reason: Anticipate and treat hyperpyrexia with cooling measures

This choice is incorrect. Hyperpyrexia (extremely high fever) is not a common immediate concern following naloxone administration. The primary focus should be on the client’s respiratory status and vital signs. Treating hyperpyrexia would be important if it were present, but it is not typically associated with naloxone administration.

A. Limit fluid intake to 1,000 mL of fluid per day. B. Adjust the dose if you feel out of control. C. Have serum lithium levels checked every 6 months. D. Do not reduce normal dietary sodium intake.

Correct Answer is D

Explanation

d. Do not reduce normal dietary sodium intake.

Explanation of Choices

Choice A Reason: Limit Fluid Intake to 1,000 mL of Fluid per Day

Limiting fluid intake to 1,000 mL per day is not recommended for clients taking lithium carbonate. Adequate hydration is crucial because lithium can affect kidney function and fluid balance. Dehydration can increase lithium levels in the blood, leading to toxicity. Therefore, clients should maintain normal fluid intake to ensure proper hydration and avoid complications.

Choice B Reason: Adjust the Dose if You Feel Out of Control

Clients should never adjust their lithium dose on their own. Lithium has a narrow therapeutic range, meaning the difference between an effective dose and a toxic dose is small. Any changes in dosage should be made under the supervision of a healthcare provider to avoid the risk of lithium toxicity or subtherapeutic levels. Self-adjusting the dose can lead to serious health risks.

Choice C Reason: Have Serum Lithium Levels Checked Every 6 Months

While regular monitoring of serum lithium levels is essential, checking levels every 6 months may not be sufficient. Initially, serum lithium levels should be checked more frequently, such as every 1 to 2 weeks, until stable therapeutic levels are achieved. After stabilization, levels are typically monitored every 3 to 6 months, depending on the patient’s clinical status and any changes in medication or health condition. Regular monitoring helps ensure the medication remains within the therapeutic range and prevents toxicity.

Choice D Reason: Do Not Reduce Normal Dietary Sodium Intake

Maintaining normal dietary sodium intake is crucial for clients taking lithium. Sodium levels in the body can affect lithium levels; a decrease in sodium intake can lead to higher lithium levels and increase the risk of toxicity. Conversely, an increase in sodium intake can lower lithium levels, reducing its effectiveness. Therefore, clients should be advised to maintain a consistent sodium intake to help stabilize lithium levels in the blood.

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who just received naloxone. Which nursing intervention is the highest priority?

Correct Answer is B

Explanation

A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?

Correct Answer is D

Explanation

A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS. Calculate the rate at which the nurse should set the infusion pump.

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

When a client with a personality disorder uses self-destructive behavior as a way of getting needs met, the staff observe the behavior closely because:

Several children come to the Emergency Department for treatment. The situation that would cause the nurse to have the highest suspicion of child abuse would be:

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