Nokea
A client has been diagnosed with borderline personality disorder, and a nurse is providing care. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct Answer: A
Rationale: Implementing a no-harm contract is a crucial intervention for clients with borderline personality disorder as it helps establish an agreement between the client and the healthcare provider to abstain from self-harming behaviors. This contract aims to promote the client's safety by enhancing awareness and providing a structured approach in managing impulses and emotions.
You may also like to solve these questions
Which client action is an example of the defense mechanism of displacement?
- A. A man kicks his dog after an argument with his boss.
- B. A woman yells at her children after a stressful day at work.
- C. A student immerses herself in studying to avoid thinking about a recent breakup.
- D. A person channels aggressive impulses into playing a sport.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse not monitor for? Select all that apply.
- A. Tardive dyskinesia
- B. Neuroleptic malignant syndrome
- C. Orthostatic hypotension
- D. Hyperglycemia
Correct Answer: A
Rationale: The nurse should not monitor for tardive dyskinesia as it is a potential long-term side effect of antipsychotic medications. However, the nurse should monitor for neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia as these are common side effects associated with antipsychotic medications. Tardive dyskinesia is characterized by involuntary movements of the face, tongue, and extremities and may develop after prolonged use of antipsychotic drugs.
A healthcare professional is assessing a client who is experiencing severe anxiety. Which of the following symptoms should the healthcare professional expect to observe?
- A. Restlessness
- B. Rapid heart rate
- C. Sweating
- D. Dry mouth
Correct Answer: B
Rationale: Rapid heart rate is a characteristic symptom of severe anxiety due to the body's fight-or-flight response being activated. This physiological response leads to an increased heart rate to prepare the body to deal with perceived threats. Healthcare professionals should be vigilant in monitoring and managing this symptom in clients experiencing severe anxiety.
A healthcare provider is assessing a client with generalized anxiety disorder (GAD). Which of the following findings shouldn't the healthcare provider expect?
- A. Restlessness
- B. Fatigue
- C. Excessive worry
- D. Mania
Correct Answer: D
Rationale: In clients with generalized anxiety disorder (GAD), common symptoms include restlessness, fatigue, excessive worry, and irritability. Mania is not typically associated with GAD; instead, it is a key feature of bipolar disorder. Therefore, the healthcare provider should not expect to find mania in a client with GAD.
When assessing a client with suspected bipolar disorder, which of the following findings should the nurse not expect?
- A. Periods of elevated mood
- B. Decreased need for sleep
- C. Flight of ideas
- D. Anhedonia
Correct Answer: D
Rationale: In bipolar disorder, common findings include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, the inability to feel pleasure, is more indicative of conditions like major depressive disorder. Therefore, the nurse should not expect to find anhedonia in a client with suspected bipolar disorder.