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 A

Explanation

Choice A Reason:

This statement indicates that the client understands the nature of recovery from alcohol abuse. Recovery is indeed a lifelong process that involves continuous effort and commitment. Recognizing that recovery comes in steps shows that the client is aware of the ongoing nature of the process and the need for sustained effort and support. This understanding is crucial for successful long-term recovery.

Choice B Reason:

This statement is incorrect because it reflects a misunderstanding of the recovery process. Detoxification is just the first step in recovery, and it involves removing alcohol from the body. However, recovery involves much more than just detoxification. It includes ongoing therapy, support groups, lifestyle changes, and coping strategies to maintain sobriety and prevent relapse. Therefore, thinking that recovery is complete after detoxification is a misconception.

Choice C Reason:

This statement is also incorrect because it suggests that the goal of recovery is merely to decrease drinking. The goal of recovery from alcohol abuse is to achieve and maintain sobriety, not just to reduce alcohol consumption. Effective recovery involves abstaining from alcohol, addressing the underlying issues that led to alcohol abuse, and developing healthy coping mechanisms and support systems.

Choice D Reason:

While Al-Anon can indeed assist in the recovery process, this statement alone does not indicate that the client has fully understood the nature of recovery. Al-Anon is a support group for friends and family members of people with alcohol use disorder, and it can provide valuable support and resources. However, recognizing the lifelong and step-by-step nature of recovery is a more comprehensive indication of learning.

A. I feel so defeated and want to hide after I have binged. B. I am able to control the pace of my bingeing when I start getting full. C. My binges usually start off with feeling hungry. D. I binge to reward myself for completing difficult tasks.

Correct Answer is A

Explanation

The correct answer is a. I feel so defeated and want to hide after I have binged.

Choice A Reason:

Individuals with binge-eating disorder often experience intense feelings of shame, guilt, and defeat after a binge episode. This emotional response is a hallmark of the disorder and can lead to further cycles of binge eating as a way to cope with these negative emotions. The statement “I feel so defeated and want to hide after I have binged” accurately reflects the emotional turmoil that accompanies binge-eating episodes.

Choice B Reason:

The statement “I am able to control the pace of my bingeing when I start getting full” is not typically associated with binge-eating disorder. People with this disorder often feel a loss of control over their eating during a binge episode and are unable to stop even when they are full. This lack of control is a key diagnostic criterion for binge-eating disorder.

Choice C Reason:

While feeling hungry can trigger a binge, it is not the primary characteristic of binge-eating disorder. The disorder is more about the uncontrollable nature of the eating episodes and the emotional distress that follows, rather than just responding to hunger. Therefore, the statement “My binges usually start off with feeling hungry” does not fully capture the essence of the disorder.

Choice D Reason:

Binge-eating as a reward for completing difficult tasks is not a typical feature of binge-eating disorder. The disorder is more about using food as a way to cope with negative emotions rather than as a reward. The statement “I binge to reward myself for completing difficult tasks” does not align with the common emotional triggers for binge-eating episodes.

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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

The nurse is educating clients about recovery from alcohol abuse. Which statement by the client indicates that learning has occurred?

Correct Answer is A

Explanation

A nurse is caring for a client who has a binge-eating disorder. Which of the following statements should the nurse expect from this client?

Correct Answer is A

Explanation

A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is aware that the major health complication associated with anorexia nervosa is:

A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client’s parents reported that they have run away several times and are abusive towards them. The nurse should anticipate that the diagnosis will be:

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.

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

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: