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Priority nursing interventions for a client with borderline personality disorder who has a history of self-mutilation and is currently angry, irritable, and impulsive would be:
- A. Establishing a contract for safety with the client
- B. Teaching the client ways to manage anger
- C. Helping the client tolerate feelings
- D. Implementing behavioral modification
Correct Answer: A
Rationale: The correct answer is A: Establishing a contract for safety with the client. This is the priority intervention as it focuses on ensuring the client's immediate safety. By setting up a contract for safety, the nurse can collaborate with the client on identifying warning signs and developing a plan to prevent self-harm.
Choice B (Teaching the client ways to manage anger) and Choice C (Helping the client tolerate feelings) are important interventions but may not be as urgent as ensuring the client's safety in this scenario.
Choice D (Implementing behavioral modification) is not the priority because the client's safety needs to be addressed first before focusing on behavioral changes.
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Which of the following is a priority intervention for a patient with bulimia nervosa who has been purging?
- A. Ensure the patient has access to therapy and counseling.
- B. Assess and monitor the patient's electrolyte levels.
- C. Encourage the patient to maintain a balanced diet.
- D. Provide education about the dangers of eating disorders.
Correct Answer: B
Rationale: The correct answer is B: Assess and monitor the patient's electrolyte levels. This is the priority intervention because purging in bulimia nervosa can lead to electrolyte imbalances, which can be life-threatening. Monitoring electrolyte levels is crucial to prevent complications such as cardiac arrhythmias or organ damage.
A: Ensuring access to therapy and counseling is important but not the priority in this case where immediate medical attention is needed for potential electrolyte imbalances.
C: Encouraging a balanced diet is essential in the long term but not the immediate priority when dealing with the potential medical complications of purging.
D: Providing education about dangers is important, but it is not the most critical intervention at this moment compared to monitoring electrolyte levels.
Which complication should a nurse monitor for when treating a patient with bulimia nervosa who is experiencing frequent vomiting?
- A. Hypokalemia and dental enamel erosion.
- B. Hyperkalemia and elevated blood pressure.
- C. Severe dehydration and low blood sugar.
- D. Hypercalcemia and weight gain.
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia and dental enamel erosion.
1. Bulimia nervosa involves frequent vomiting, leading to loss of potassium (hypokalemia) due to electrolyte imbalance.
2. Vomiting also damages tooth enamel, causing dental erosion.
3. Hyperkalemia and elevated blood pressure (choice B) are not typically associated with bulimia.
4. Severe dehydration and low blood sugar (choice C) are possible but not the primary concerns.
5. Hypercalcemia and weight gain (choice D) are not common complications of bulimia.
Which behaviors would indicate the need for further assessment to consider avoidant personality disorder?
- A. Withholding of feelings and low self-esteem
- B. Insistence on others conforming to own methods
- C. Engaging in impulsive acts like unsafe sex
- D. Initial charm dissolving into coldness and blaming others
Correct Answer: A
Rationale: Step 1: Withholding of feelings is a key feature of avoidant personality disorder, indicating difficulty in expressing emotions.
Step 2: Low self-esteem is also characteristic, as individuals with this disorder often feel inadequate and inferior.
Step 3: Insistence on others conforming to own methods (B) is more indicative of narcissistic personality disorder.
Step 4: Engaging in impulsive acts like unsafe sex (C) is more aligned with borderline personality disorder.
Step 5: Initial charm dissolving into coldness and blaming others (D) is a trait of antisocial personality disorder.
Which of these assessment findings would indicate that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault?
- A. Patient is very demanding and controlling in manner when dealing with staff.
- B. Patient appears to be confused, restless, and fearful when left alone.
- C. Patient uses profanity to describe the events surrounding the attack.
- D. Patient experiences a panic attack on the anniversary of the attack.
Correct Answer: B
Rationale: The correct answer is B because exhibiting confusion, restlessness, and fear when left alone aligns with the acute stage of sexual assault trauma. During this stage, victims often experience shock, disbelief, and heightened anxiety. This behavior reflects immediate emotional distress and trauma response. Choice A indicates characteristics of control and demanding behavior, which are not typically seen in the acute stage. Choice C suggests using profanity, which may vary based on individual coping mechanisms. Choice D indicates a specific trigger response on the anniversary, suggesting a later stage of processing trauma, not the acute phase.
It is a secondary dementia indicated by loss of recent memory and disorientation to time and place.
- A. Alzheimer's disease.
- B. Vascular dementia.
- C. Lewy body dementia.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A: Alzheimer's disease. Alzheimer's disease is a common type of dementia characterized by progressive cognitive decline, including loss of recent memory and disorientation to time and place. This is due to the accumulation of amyloid plaques and neurofibrillary tangles in the brain. Vascular dementia (B) is caused by reduced blood flow to the brain, leading to cognitive impairment. Lewy body dementia (C) is characterized by the presence of abnormal protein deposits called Lewy bodies in the brain. Choosing D (None of the above) would be incorrect as Alzheimer's disease specifically matches the description provided in the question.