Nokea
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
- A. You should cancel your upcoming business trip.
- B. Your spouse should come to the clinic today to be assessed.
- C. It sounds like you are having a difficult time coping with your spouse's behavior.
- D. It is best to ignore your spouse's behavior because your spouse is doing this to gain attention.
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.
You may also like to solve these questions
The nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should recognize that it is a priority to
- A. gather supplies for an IV bolus of 0.9% sodium chloride
- B. prepare the client for an IV infusion of regular insulin
- C. request a prescription for potassium chloride
- D. obtain a urine specimen for urinalysis
Correct Answer: B
Rationale: In diabetic ketoacidosis, insulin administration is the priority to correct hyperglycemia and halt ketogenesis, addressing the underlying metabolic crisis.
A client with acquired immunodeficiency syndrome has a T cell count of 180 . The medication frequently used for the client with T cell counts less than 200 is:
- A. Garamycin (gentamicin)
- B. Zovirax (acyclovir)
- C. Pentam (pentamidine)
- D. Immune globulin
Correct Answer: C
Rationale: Pentamidine is used for Pneumocystis prophylaxis in AIDS patients with T-cell counts <200. Gentamicin is an antibiotic, acyclovir treats herpes, and immune globulin is not specific.
The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?
- A. During a left heart catheterization, the coronary arteries can be visualized.
- B. During a left heart catheterization, holes in the heart walls can be detected.
- C. During a left heart catheterization, blood flow to the lungs can be measured.
- D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.
Correct Answer: A
Rationale: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.
Correct Answer: 655 mL
Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL
Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL
Total Output = 1450 mL
3. Net Balance:
2105 − 1450 = 655 mL net positive balance