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A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?
- A. A client who has borderline personality disorder and acts impulsively
- B. A client who has avoidant personality disorder and becomes anxious in social situations
- C. A client who has dependent personality disorder and clings to nursing staff
- D. A client who has histrionic personality disorder and seeks constant attention
Correct Answer: A
Rationale: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support.
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A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?
- A. Inform the parents that the findings must be reported to authorities.
- B. Complete an incident report for risk management.
- C. Interview the child about the suspected abuse with a parent present.
- D. Avoid asking the child what caused the injury.
Correct Answer: A
Rationale: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.
A nurse is collecting data from a client who has been admitted with manifestations of paranoia. Which of the following findings should the nurse identify as a risk factor for schizophrenia?
- A. The client's home has lead paint on the walls.
- B. The client's twin sibling has schizophrenia.
- C. The client is opioid dependent.
- D. The client's mother used tobacco products during pregnancy.
Correct Answer: B
Rationale: Having a family member, especially a twin sibling, with schizophrenia significantly increases the risk of developing the condition. Genetics play a crucial role in the development of schizophrenia, and individuals with a first-degree relative who has schizophrenia are at a higher risk of developing the disorder.
A nurse is reinforcing teaching with a client who is scheduled for implantation of a vagus nerve stimulator. Which of the following statements should the nurse include in the teaching?
- A. You might have extreme fatigue for several weeks after the device is implanted.
- B. Your voice might sound hoarse after the device is implanted.
- C. Your depression will improve within 72 hours after the device is implanted.
- D. You can schedule an appointment with your provider to turn the device off.
Correct Answer: B
Rationale: Hoarseness or changes in voice is a common side effect after the implantation of a vagus nerve stimulator. The stimulator affects the vagus nerve, which is close to the vocal cords. As a result, stimulation can lead to changes in voice, including hoarseness. Patients should be informed of this potential side effect so they are not alarmed if it occurs.
A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. As long as a person is not vomiting after eating they do not have bulimia nervosa.
- B. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- C. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- D. People who have bulimia nervosa eat an average amount of food on a daily basis.
Correct Answer: C
Rationale: Bulimia nervosa can be difficult to detect because individuals with this disorder often maintain a weight that is within the average or ideal range. This can make it challenging for others to recognize the presence of an eating disorder, as the physical appearance may not immediately suggest a problem.