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A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
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A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation?
- A. Chest x-ray
- B. ECG
- C. Coagulation studies
- D. Liver function test
Correct Answer: B
Rationale: The correct answer is B: ECG. A provider may order an ECG during the medical evaluation of a client with bulimia nervosa to assess for any potential cardiac complications, such as electrolyte imbalances or arrhythmias due to purging behaviors. This test helps in evaluating the overall cardiac health of the client. Chest x-ray (A) is not typically indicated in the evaluation of bulimia nervosa unless there are specific respiratory symptoms. Coagulation studies (C) are not directly related to the diagnosis of bulimia nervosa. Liver function test (D) is not a common diagnostic procedure for bulimia nervosa unless there are specific concerns about liver function due to other factors.
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?
- A. Bradycardia
- B. Stupor
- C. Afebrile
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Lorazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including hypertension. Alcohol withdrawal often leads to increased sympathetic nervous system activity, causing elevated blood pressure. Lorazepam helps to reduce this symptom by promoting relaxation and reducing anxiety. Bradycardia (A), stupor (B), and afebrile (C) are not indications for lorazepam administration in alcohol withdrawal. Bradycardia and stupor may require further evaluation for potential complications, while afebrile state does not directly warrant lorazepam use.
A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.
A nurse is reviewing laboratory findings for a client who has been taking lithium for 6 months. Which of the following findings should the nurse report to the provider?
- A. Lithium level 0.8 mEq/L
- B. Sodium 130 mEq/L
- C. Creatinine 1.5 mg/dL
- D. WBC 8,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. This finding should be reported because an elevated creatinine level indicates impaired kidney function, which can lead to lithium toxicity. Lithium is primarily excreted by the kidneys, and impaired renal function can result in lithium accumulation in the body, increasing the risk of adverse effects. Reporting this finding promptly will allow the provider to adjust the dosage of lithium to prevent toxicity.
Choices A, B, and D are within normal ranges and do not directly indicate lithium toxicity. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Sodium level of 130 mEq/L is also within normal limits. WBC count of 8,000/mm³ is normal and not directly related to lithium toxicity. Therefore, these findings do not require immediate reporting compared to the elevated creatinine level.
A nurse in a psychiatric unit is providing discharge teaching to a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following instructions should the nurse include?
- A. Take the medication in the morning
- B. Expect improvement within 24 hours
- C. Discontinue the medication when symptoms improve
- D. Avoid foods high in tyramine
Correct Answer: A
Rationale: The correct answer is A: Take the medication in the morning. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression. Taking it in the morning helps prevent insomnia, a common side effect. Option B is incorrect as improvement may take weeks, not 24 hours. Option C is wrong as stopping abruptly can lead to withdrawal symptoms. Option D is irrelevant as tyramine interactions are associated with MAOIs, not SSRIs.