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:

Hallucinations are not a common side effect of Buspar (Buspirone) and could indicate a serious reaction to the medication. If a client experiences hallucinations, it is crucial for the nurse to report this to the provider immediately as it may require medical intervention or adjustment of the medication.

Choice B reason:

Discolored urine can be concerning, but it is not typically associated with Buspar (Buspirone). It could be related to other factors such as diet, hydration levels, or other medications. However, if the discoloration is persistent or accompanied by other symptoms, it should be reported to the provider.

Choice C reason:

Decreased appetite might occur with Buspar (Buspirone), but it is generally not considered a serious side effect. If the decreased appetite leads to significant weight loss or nutritional deficiencies, it should be discussed with the provider.

Choice D reason:

Sweating can be a side effect of many medications and is not usually a cause for concern with Buspar (Buspirone). However, if sweating is excessive or causes discomfort, it may be worth mentioning to the provider.

A. Reality orientation B. A sense of responsibility C. A sense of survival D. Unconditional love

Correct Answer is D

Explanation

Choice A reason:

Reality orientation is about helping individuals understand their surroundings and the current situation. The statement in question does not directly affect the child's ability to perceive reality but rather ties the parent's affection to the child's performance, which is not related to reality orientation.

Choice B reason:

A sense of responsibility is typically encouraged by allowing children to experience the consequences of their actions and decisions. The statement made by the parent does not address the child's responsibility; instead, it places the child's worth and the parent's love as conditional upon academic performance.

Choice C reason:

A sense of survival would be hindered if the child's basic needs or safety were threatened. In this scenario, the statement does not threaten the child's sense of survival but rather their emotional security and self-worth.

Choice D reason:

Unconditional love is the concept that a parent's love for their child is not based on the child's actions or achievements. The statement made by the parent suggests that their love is conditional upon the daughter's academic success, which can severely impact the child's self-esteem. Children need to know that they are loved regardless of their achievements to develop a healthy sense of self-esteem. When parental love is perceived as conditional, it can lead to feelings of insecurity and unworthiness.

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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 is taking care of a client who has generalized anxiety disorder and is taking Buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

Correct Answer is A

Explanation

During a family group therapy session, the nurse overhears the client telling her daughter, "You need to do better in school so I can love you as much as I love your brother." According to Warren, this statement discourages the development of positive self-esteem by hindering which parenting focus?

Correct Answer is D

Explanation

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