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1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following test approaches should the nurse plan to take? a. Restrict participation i... n group therapy sessions. The nurse should encourage the client who has borderline personality disorder to participate in group therapy sessions to encourage appropriate interaction with other clients. b. Establish consequences for self-mutilation. The nurse should respond to self-mutilation with a neutral affect and encourage the client to write down feelings that occurred leading up to the incident. c. Maintain close observation of the client. Clients who have borderline personality disorder are at risk for self-harm during times of increased anxiety. Maintaining close observation reduces the client's risk of injury. d. Provide an unstructured environment. Providing an unstructured environment for a client who has borderline personality disorder is not an effective treatment approach because it does not provide a safe environment to protect the client from impulsive and self-injurious behavior. 2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? a. The client requires assistance with eating. The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability until Stage 7. b. The client independently manages personal finances. The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty performing complex tasks, such as managing personal finances. c. The client has bladder incontinence. The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6. d. The client is able to identify the names of family members. The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6. 3. A nurse is caring for a client who reports that the television set in the room is really a two-way radio and states, "voices are coming from the TV and everything we say in the room is being recorded." Which of the following responses should the nurse make? a. "What we say is not being recorded." The nurse should avoid negating the client’s beliefs about the delusion. This response can promote a defensive client response and interfere with the development of trust in the nurse-client relationship. b. "Let's ignore the voices and talk about something else." The nurse should ask the client directly about what the voices are saying to determine if there is a safety risk. The nurse should also avoid validating that the voices are real, which promotes the client’s beliefs about the delusion. c. "That must be very frightening." The nurse should respond to the client’s delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurseclient relationship. d. "Why do you think the TV is a two-way radio?" The nurse should avoid asking the client a "why" question, which promotes a defensive client response. 4. A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? a. Practicing problem-solving skills The nurse should encourage the client to practice problem-solving skills during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. b. Understanding of medication regimen The nurse should ensure that the client understands the medication regimen during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. c. Identifying indications of relapse The nurse should teach the client to recognize indications of relapse during the continuation phase of treatment; however, there is another intervention that is the priority during the acute phase of bipolar disorder. d. Maintaining adequate hydration The nurse should identify that the priority goal is to prevent physical exhaustion, maintain health, and meet nutritional and rest needs during the acute phase of the client’s manic episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels of priority when planning care for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow’s hierarchy of needs priority-setting framework the nurse should review physiological needs first. The nurse should then address the client’s needs by following the remaining four hierarchical levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow’s hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. 5. A nurse is preparing to administer benzodiazepine to a client with Generalized Anxiety Disorder. The nurse should tell the client to expect with of the following adverse reactions? a. Tinnitus Tinnitus is not an adverse effect of benzodiazepines. b. Bradycardia Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines. c. Halitosis Halitosis is not an adverse effect of benzodiazepines. d. Sedation The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines because of the CNS depression effects. 6. A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. The nurse should identify which of the following interventions as the priority when planning care for this client? a. Promoting and maintaining client safety The nurse should recognize that the client who has self-inflicted injuries is at risk for further [Show More]

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