Medical History: Borderline personality disorder.

Alcohol use disorder.

History of suicidal ideation.

Medication Administration Record: Fluoxetine 20 mg PO daily.

Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.

Client reports recent breakup of romantic relationship and subsequent job loss.

States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.

Client states, "I feel so alone.

There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

Instruct the client to avoid foods with tyramine.

Apply wrist restraints.

Offer sympathy and attention to maladaptive behavior.

Encourage the client to talk about feelings prior to maladaptive behavior.

Maintain same staff members caring for the client.

Answer and Explanation

The Correct Answer is F

Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.

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Correct Answer is D

Explanation

Choice A rationale:

A BUN of 22 mg/dL is slightly elevated but not a contraindication for clozapine.

Choice B rationale:

A serum potassium of 3.3 mEq/L is slightly low but not a contraindication for clozapine.

Choice C rationale:

A hematocrit of 55% is high but not a contraindication for clozapine.

Choice D rationale:

A WBC of 2,900 cells/mm² is low and can indicate agranulocytosis, a potentially life-threatening condition. Clozapine should be discontinued.

A. Refer the client for flooding therapy. B. Inform the client that the pain is not real. C. Provide reassurance to the client. D. Encourage the client to request invasive cardiac testing.

Correct Answer is C

Explanation

Choice A rationale:
Flooding therapy is not typically used for somatic symptom disorder.
Choice B rationale:
Telling a client that their pain is not real can invalidate their experience and is not a recommended approach for somatic symptom disorder.
Choice C rationale:
Providing reassurance to the client is a recommended approach when all tests are normal and there are no identified risk factors.
Choice D rationale:
Encouraging the client to request invasive cardiac testing is not typically recommended when all tests are normal and there are no identified risk factors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client in an outpatient clinic. Exhibits The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?.

A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation. Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

A nurse is caring for a client who has borderline personality disorder (BPD). Check the 6 assessment findings that require immediate follow-up:.

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?