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.

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Correct Answer is C

Explanation

The correct answer is c. Pepperoni pizza and red wine.

Choice A Reason:

Apple pie and coffee are generally safe to consume while taking MAOIs. These foods do not contain high levels of tyramine, which is the substance that can cause dangerous interactions with MAOIs. Tyramine is found in aged, fermented, or cured foods, and neither apple pie nor coffee falls into these categories.

Choice B Reason:

A bagel with cream cheese and tea is also considered safe for individuals taking MAOIs. Cream cheese is a fresh cheese and does not contain high levels of tyramine. Tea, while containing caffeine, does not pose a significant risk of tyramine interaction.

Choice C Reason:

Pepperoni pizza and red wine are high in tyramine and should be avoided by individuals taking MAOIs. Pepperoni is a cured meat, and red wine is a fermented beverage, both of which can lead to a hypertensive crisis when consumed with MAOIs. This combination can cause a dangerous spike in blood pressure, making it the correct answer to the question.

Choice D Reason:

Potato chips and diet cola do not contain high levels of tyramine and are generally safe to consume while taking MAOIs. Potato chips are not aged or fermented, and diet cola, although containing caffeine, does not pose a significant risk of tyramine interaction.

A. The diathesis-stress model assists the client in identifying their level of stress or anxiety. B. The diathesis-stress model assists in telling me how stressed a client is. C. The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress. D. The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

Correct Answer is C

Explanation

Choice A Reason: The diathesis-stress model assists the client in identifying their level of stress or anxiety.

This statement is incorrect because the diathesis-stress model does not primarily focus on helping clients identify their current levels of stress or anxiety. Instead, it is a framework used to understand how predispositional vulnerabilities (diatheses) and external stressors interact to influence the development of psychological disorders. While understanding stress levels can be part of a broader assessment, it is not the main purpose of the diathesis-stress model.

Choice B Reason: The diathesis-stress model assists in telling me how stressed a client is.

This statement is also incorrect. The diathesis-stress model is not a tool for measuring or quantifying a client’s current stress levels. Rather, it is a theoretical model that explains how stress interacts with an individual’s vulnerabilities to potentially trigger mental health issues. The model helps clinicians understand the interplay between genetic, biological, and environmental factors, but it does not provide a direct measure of stress.

Choice C Reason: The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress.

This statement is correct. The diathesis-stress model is designed to identify and understand the risk factors or vulnerabilities (diatheses) that make an individual more susceptible to developing psychological disorders when exposed to stress. These vulnerabilities can be genetic, biological, psychological, or situational. By identifying these factors, clinicians can better predict which individuals are at higher risk for developing mental health issues under stress and can tailor interventions accordingly.

Choice D Reason: The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

This statement is partially correct but not entirely accurate. While the diathesis-stress model can help in understanding the development of mental health disorders, it does not specifically identify which disorder a client has. The model provides a framework for understanding how various factors contribute to the onset of disorders, but a comprehensive clinical assessment is required to diagnose specific mental health conditions.

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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

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about food interactions with the medication, which foods will the nurse caution the client to avoid?

Correct Answer is C

Explanation

A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the model?

Correct Answer is C

Explanation

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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: