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:
High serum sodium levels do not directly cause toxic levels of valproate.
Choice B rationale:
While regular health monitoring is important, specifically performing thyroid function tests every 6 months is not a standard requirement for valproate use.
Choice C rationale:
A pretreatment electroencephalogram (EEG) is not typically required before starting valproate.
Choice D rationale:
Liver function tests must be monitored as valproate can cause liver failure that may be fatal.

A. GI discomfort and poor coordination. B. Lip smacking and tongue thrusting. C. Blurred vision and jerking motor movements. D. Fever and fluctuating blood pressure.

Correct Answer is A

Explanation

Choice A rationale:

A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.

Choice B rationale:

Lip smacking and tongue thrusting are not typically associated with lithium toxicity.

Choice C rationale:

While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.

Choice D rationale:

Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?

Correct Answer is D

Explanation

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

Correct Answer is A

Explanation

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 assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

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 teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?