Which of the following is the priority action by the nurse for a client with symptoms of depression who admits to thoughts of self-harm with a plan, and has a history of borderline personality disorder, depression, and substance abuse?

Review the client's toxicology laboratory report.

Initiate suicide precautions.

Administer the Hamilton Depression Scale.

Make a contract with the client for behavior in the unit.

Answer and Explanation

The Correct Answer is B

Choice A reason:

While reviewing the client's toxicology laboratory report is important to understand any substance use that may be contributing to the client's current state, it is not the immediate priority. The priority is to ensure the client's safety.

Choice B reason:

Initiating suicide precautions is the most critical and immediate action when a client admits to thoughts of self-harm with a plan. This involves creating a safe environment, providing constant supervision, and possibly removing harmful objects to prevent the client from acting on these thoughts.

Choice C reason:

Administering the Hamilton Depression Scale can help in assessing the severity of depression, but it is not the first priority. The immediate concern is to protect the client from self-harm.

Choice D reason:

Making a contract with the client for behavior in the unit can be a useful part of the treatment plan, particularly for clients with borderline personality disorder. However, it is not the first action to take when a client is at immediate risk for self-harm.

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Correct Answer is A

Explanation

Choice A reason:

Primary prevention in community mental health is focused on reducing the incidence of mental disorders within the population. This proactive approach involves strategies and interventions designed to prevent the onset of mental health issues before they manifest. It includes enhancing individual resilience, fostering a supportive environment, and promoting mental well-being to lower the incidence and impact of mental health problems.

Choice B reason:

Services aimed at reducing the residual defects associated with severe and persistent mental illness fall under tertiary prevention. Tertiary prevention focuses on reducing the negative impact of an already established disease by restoring function and reducing disease-related complications.

Choice C reason:

Early identification of problems and prompt initiation of effective treatment are aspects of secondary prevention. Secondary prevention aims to reduce the impact of a disease that has already occurred, through early detection and appropriate treatment to halt or slow its progression.

Choice D reason:

Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness can be considered part of both secondary and tertiary prevention. These interventions work to alleviate the effects of an existing condition and prevent it from becoming more severe or prolonged.

A. Monitor the client closely to prevent self-mutilation. B. Set limits to prevent exploitation of other clients. C. Give positive feedback when the client is assertive with staff or clients. D. Discourage flamboyant or seductive behaviors.

Correct Answer is C

Explanation

Choice A Reason:

Monitoring the client closely to prevent self-mutilation is crucial for clients with certain personality disorders, such as borderline personality disorder, where self-harm is more prevalent. However, dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. Self-mutilation is not a primary concern for this disorder.

Choice B Reason:

Setting limits to prevent exploitation of other clients is important in managing clients with antisocial personality disorder, who may manipulate or exploit others. Clients with dependent personality disorder are more likely to be overly reliant on others rather than exploit them. Therefore, this action is not the highest priority for this specific disorder.

Choice C Reason:

Giving positive feedback when the client is assertive with staff or clients is the most appropriate action. Clients with dependent personality disorder often struggle with making decisions and expressing their own needs due to their excessive reliance on others. Encouraging and reinforcing assertive behavior helps them develop independence and self-confidence, which are crucial for their treatment and overall well-being.

Choice D Reason:

Discouraging flamboyant or seductive behaviors is more relevant for clients with histrionic personality disorder, where attention-seeking and dramatic behaviors are common. Clients with dependent personality disorder do not typically exhibit these behaviors, so this action is not the highest priority.

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Which of the following is the priority action by the nurse for a client with symptoms of depression who admits to thoughts of self-harm with a plan, and has a history of borderline personality disorder, depression, and substance abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is discussing community mental health with a group of nursing students. Based on the public health model, which of the following statements made by one of the students indicates correct information about primary prevention?

Correct Answer is A

Explanation

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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