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 C

Explanation

Choice A Reason:

Warning the client that further disruptions will result in seclusion can be perceived as punitive and may escalate the client's behavior. While setting consequences is important, it should be done in a way that is therapeutic and supportive rather than threatening.

Choice B Reason:

Asking the client to recommend consequences for her disruptive behavior may not be effective during a manic episode. Clients experiencing mania often have impaired judgment and may not be able to provide appropriate or realistic consequences. It is more effective for the nurse to set clear and consistent limits.

Choice C Reason:

Setting limits on the client's behavior and being consistent in approach is the most appropriate action. Clients experiencing mania benefit from clear boundaries and consistent responses from staff. This helps to create a structured environment that can reduce anxiety and prevent further disruptive behavior. Consistency in approach also helps the client understand the expectations and consequences of their actions.

Choice D Reason:

Ignoring the client's behavior is not appropriate, even though it is consistent with her illness. Disruptive behavior can affect other clients and the overall environment of the unit. It is important to address the behavior in a therapeutic manner to maintain a safe and supportive environment for all clients.

A. "This medication will decrease your symptoms of OCD." B. "This medication may cause excessive salivation." C. "You can stop taking the medication if the side effects are bothersome." D. "You may experience dizziness upon standing while taking this medication."

Correct Answer is D

Explanation

Choice A Reason:

Haloperidol is primarily used to treat symptoms of schizophrenia, not Obsessive-Compulsive Disorder (OCD). While it may have some impact on OCD symptoms due to its dopamine-blocking effects, it is not the primary indication for its use.

Choice B Reason:

Excessive salivation is not a common side effect of haloperidol. The medication is more commonly associated with dry mouth rather than increased salivation. However, it can cause other extrapyramidal side effects such as tremors, rigidity, and bradykinesia.

Choice C Reason:

Patients should not stop taking haloperidol without consulting their healthcare provider, even if side effects are bothersome. Abrupt discontinuation can lead to withdrawal symptoms and a relapse of schizophrenia symptoms. Instead, they should discuss any side effects with their provider to adjust the treatment plan as necessary.

Choice D Reason:

Orthostatic hypotension, which can cause dizziness upon standing, is a known side effect of haloperidol. This occurs due to haloperidol's blockade of alpha-adrenergic receptors, leading to a drop in blood pressure when changing positions.

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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 caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

Which of the following should be the appropriate action by a nurse attempting to develop a therapeutic relationship with a client?

A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?

A nurse is caring for a client diagnosed with schizophrenia. The client states, "Did you know that I am engaged to the Prince of England?" The nurse should document that the client is experiencing which of the following types of delusions?

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?

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

A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?