Nokea
A client with borderline personality disorder exhibits self-mutilating behavior. Which nursing intervention should the nurse implement to address this behavior?
- A. Encourage the client to discuss underlying issues.
- B. Set firm limits on the client's behavior.
- C. Provide a safe environment to prevent self-harm.
- D. Discuss the consequences of self-mutilating behavior.
Correct Answer: C
Rationale: The correct intervention when dealing with a client exhibiting self-mutilating behavior, especially with borderline personality disorder, is to provide a safe environment to prevent self-harm. This approach is crucial in ensuring the client's physical safety and well-being. Setting firm limits may be appropriate in some situations, but the immediate priority is to prevent self-harm. Encouraging the client to discuss underlying issues and discussing consequences are important aspects of therapy; however, in the case of acute self-mutilating behavior, the primary focus should be on creating a safe environment to prevent harm.
You may also like to solve these questions
A client with bipolar disorder is in the manic phase. Which nursing intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Encourage the client to participate in group activities.
- C. Monitor the client closely for signs of exhaustion.
- D. Encourage the client to rest and sleep as needed.
Correct Answer: A
Rationale: During the manic phase of bipolar disorder, individuals may engage in impulsive behaviors that can put them at risk of harm. Providing a structured environment with minimal stimuli can help reduce the risk of injury by minimizing triggers for impulsive actions. This intervention promotes a safe and controlled setting for the client, which is crucial in managing the symptoms of mania. Encouraging the client to participate in group activities (Choice B) may increase stimuli and potentially exacerbate manic symptoms. Monitoring for signs of exhaustion (Choice C) is important but does not directly address the safety concerns related to impulsive behaviors during mania. Encouraging the client to rest and sleep as needed (Choice D) may be challenging during the manic phase when individuals typically experience decreased need for sleep.
A client is experiencing severe anxiety. Which of the following is an appropriate intervention?
- A. Encourage the client to participate in group therapy sessions.
- B. Encourage the client to verbalize feelings of anxiety.
- C. Encourage the client to limit caffeine intake.
- D. Encourage the client to avoid stressful situations.
Correct Answer: B
Rationale: Encouraging the client to verbalize feelings of anxiety is an appropriate intervention for severe anxiety. Verbalizing emotions can help the client process their feelings and reduce the intensity of anxiety. It promotes emotional expression and may lead to a better understanding of the underlying causes of anxiety, paving the way for effective coping strategies. Choices A, C, and D are not the most appropriate interventions for severe anxiety. While group therapy can be beneficial, it may not be suitable for someone experiencing severe anxiety. Limiting caffeine intake and avoiding stressful situations are helpful strategies but may not address the root of the severe anxiety or provide immediate relief.
A healthcare professional is assessing a client who has been diagnosed with major depressive disorder. Which symptom should the healthcare professional expect to observe?
- A. Increased energy
- B. Weight gain
- C. Increased appetite
- D. Restlessness
Correct Answer: B
Rationale: Weight gain is a common symptom of major depressive disorder. Individuals with major depressive disorder often experience changes in appetite, leading to weight gain or loss. This symptom is related to disruptions in the individual's eating habits and metabolism, which are commonly associated with depression. Choices A, C, and D are incorrect because increased energy, increased appetite, and restlessness are not typical symptoms of major depressive disorder. In fact, individuals with depression often experience fatigue, changes in appetite, and feelings of restlessness or agitation.
A client with major depressive disorder expresses feelings of hopelessness. Which nursing intervention should the nurse implement to address these feelings?
- A. Encourage the client to engage in physical activity.
- B. Provide opportunities for the client to make decisions.
- C. Help the client identify positive aspects of their life.
- D. Encourage the client to verbalize feelings of hopelessness.
Correct Answer: C
Rationale: When a client with major depressive disorder expresses feelings of hopelessness, helping them identify positive aspects of their life can be an effective nursing intervention. This approach can assist in shifting their focus from negativity to positivity, promoting a sense of hope and potentially improving their overall outlook and well-being. By highlighting the positive aspects, the nurse can support the client in recognizing reasons for hope and encourage a more optimistic perspective, which can aid in addressing and alleviating feelings of hopelessness. Encouraging physical activity (Choice A) may be beneficial for overall well-being but may not directly address feelings of hopelessness. Providing opportunities for decision-making (Choice B) can empower the client but may not specifically target feelings of hopelessness. Encouraging verbalization of feelings (Choice D) is important but may not be as effective as helping the client shift their focus to positive aspects of life.
A healthcare professional is assessing a client diagnosed with body dysmorphic disorder. Which of the following findings should the healthcare professional expect?
- A. Preoccupation with a perceived physical defect
- B. Fear of gaining weight
- C. Excessive worry about physical symptoms
- D. Persistent depressive mood
Correct Answer: A
Rationale: The correct answer is A: Preoccupation with a perceived physical defect. Individuals with body dysmorphic disorder exhibit an obsessive preoccupation with a perceived flaw in their physical appearance, which is often minor or not noticeable to others. This preoccupation causes distress and leads to repetitive behaviors like mirror checking or seeking reassurance about their appearance. Choices B, C, and D are incorrect because fear of gaining weight is more characteristic of an eating disorder, excessive worry about physical symptoms may be seen in somatic symptom disorder, and persistent depressive mood aligns more with depressive disorders rather than body dysmorphic disorder.