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A client has been diagnosed with borderline personality disorder, and a nurse is providing care. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct Answer: A
Rationale: Implementing a no-harm contract is a crucial intervention for clients with borderline personality disorder as it helps establish an agreement between the client and the healthcare provider to abstain from self-harming behaviors. This contract aims to promote the client's safety by enhancing awareness and providing a structured approach in managing impulses and emotions.
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During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct Answer: C
Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.
A healthcare professional is assessing a client with obsessive-compulsive disorder (OCD). Which of the following findings shouldn't the healthcare professional expect?
- A. Recurrent, intrusive thoughts
- B. Compulsive behaviors
- C. Delusions of grandeur
- D. Avoidance of situations that trigger obsessions
Correct Answer: C
Rationale: In obsessive-compulsive disorder (OCD), common findings include recurrent, intrusive thoughts (obsessions), compulsive behaviors, and avoidance of situations that trigger obsessions. Delusions of grandeur, which involve having an exaggerated sense of power, importance, or identity, are not typically associated with OCD. It is important to differentiate between the specific characteristics of OCD and other mental health conditions to provide accurate care and interventions for clients.
A healthcare professional is assessing a client with suspected substance use disorder. Which of the following findings should the healthcare professional not expect?
- A. Neglect of responsibilities
- B. Increased tolerance to the substance
- C. Withdrawal symptoms when not using the substance
- D. Unsuccessful attempts to cut down or control use
Correct Answer: B
Rationale: Findings in a client with substance use disorder typically include neglect of responsibilities, withdrawal symptoms when not using the substance, and unsuccessful attempts to cut down or control use. Increased tolerance to the substance is a common phenomenon in substance use disorder and is expected as the individual requires higher doses to achieve the same effect.
A healthcare professional is assessing a client's use of defense mechanisms. Which statement would indicate to the healthcare professional that the client is using the defense mechanism of projection?
- A. The client accuses others of being angry when it is the client who is angry.
- B. The client refuses to acknowledge a problem despite evidence to the contrary.
- C. The client attributes his own feelings of hostility to others.
- D. The client avoids dealing with painful feelings by focusing on something else.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is providing education to a client who has been prescribed lithium for bipolar disorder. Which statement by the client indicates an accurate understanding of the medication?
- A. I should avoid eating aged cheeses and processed meats.
- B. I need to maintain a consistent sodium intake.
- C. I should drink plenty of fluids to stay hydrated.
- D. I can take over-the-counter medications without consulting my doctor.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.