Nursing Elites

1. A client with borderline personality disorder exhibits self-mutilating behavior. Which nursing intervention should the nurse implement to address this behavior?

• A. Encourage the client to discuss underlying issues.
• B. Set firm limits on the client's behavior.
• C. Provide a safe environment to prevent self-harm.
• D. Discuss the consequences of self-mutilating behavior.

Correct answer: C

Rationale: The correct intervention when dealing with a client exhibiting self-mutilating behavior, especially with borderline personality disorder, is to provide a safe environment to prevent self-harm. This approach is crucial in ensuring the client's physical safety and well-being. Setting firm limits may be appropriate in some situations, but the immediate priority is to prevent self-harm. Encouraging the client to discuss underlying issues and discussing consequences are important aspects of therapy; however, in the case of acute self-mutilating behavior, the primary focus should be on creating a safe environment to prevent harm.

2. What is the most appropriate intervention for a patient experiencing a panic attack?

• A. Encourage deep, slow breathing.
• B. Encourage the patient to talk about their feelings.
• C. Leave the patient alone to calm down.
• D. Engage the patient in a physical activity.

Correct answer: A

Rationale: Encouraging deep, slow breathing is the most appropriate intervention for a patient experiencing a panic attack. This technique can help the patient regulate their breathing, reduce hyperventilation, and promote relaxation, which are essential in managing the symptoms of a panic attack. Choice B, encouraging the patient to talk about their feelings, may not be effective during an acute panic attack as the focus should be on calming the patient down. Choice C, leaving the patient alone, can lead to increased feelings of fear and isolation during a panic attack. Choice D, engaging the patient in physical activity, may exacerbate symptoms as it can increase the feeling of being out of control.

3. A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, 'You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing:'

• A. A higher dosage
• B. Once-weekly dosing
• C. A lower dosage
• D. A different drug

Correct answer: C

Rationale: During the maintenance therapy stage for bipolar I disorder, it is common to lower the dosage of lithium to prevent side effects while still maintaining stability. Lowering the dosage helps to find the lowest effective dose that can still manage symptoms effectively with minimal side effects.

4. Before discharge from the chemical dependency unit, clients are introduced to different community resources. Which of the following resources would be best for a teenage client, who has been abusing over-the-counter sedatives and is ready for discharge in two days?

• A. Detoxification center
• B. Home care
• C. Assertive community team
• D. Twelve-step recovery group

Correct answer: A

Rationale: For a teenage client who has been abusing over-the-counter sedatives and is ready for discharge in two days, the best resource would be a detoxification center. This specialized facility can provide the necessary medical and psychological support to safely manage the withdrawal symptoms associated with substance abuse. It is crucial to ensure a safe and supervised detox process for the client's well-being and successful recovery.

5. When assessing a client's behavior for potential aggression, what behavior would be recognized as the highest predictor of future violence?

• A. Pacing and restlessness
• B. Verbal threats
• C. History of violence
• D. Substance abuse

Correct answer: C

Rationale: A history of violence is considered the highest predictor of future violence. Clients who have a history of violent behavior are more likely to engage in violent acts in the future compared to those who exhibit other behaviors such as pacing, making verbal threats, or having substance abuse issues. Understanding a client's history of violence is crucial in assessing the risk of potential aggression and violence. Pacing and restlessness, verbal threats, and substance abuse can be concerning behaviors but do not carry the same predictive value for future violence as a documented history of violent behavior.

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