the rn is providing care for a client diagnosed with borderline personality disorder who has self inflicted lacerations on the abdomen which approach
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Nursing Elites

HESI RN

Mental Health HESI Quizlet

1. When changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen, which approach should the RN use?

Correct answer: B

Rationale: The correct approach for the RN when changing the dressing for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen is to perform the dressing change in a non-judgmental manner. This approach helps maintain therapeutic rapport and respect for the client's situation. Choice A is incorrect because providing detailed and thorough explanations may not be as important as maintaining a non-judgmental attitude. Choice C is incorrect because asking why the client cut their own abdomen may come across as accusatory or threatening, which can be counterproductive in building trust. Choice D is incorrect because the RN should be equipped to handle the dressing change independently while ensuring a supportive and non-judgmental environment for the client.

2. A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?

Correct answer: B

Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.

3. What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?

Correct answer: B

Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.

4. The client is preparing to discontinue the use of a sedative-hypnotic medication. Which instruction should the nurse include?

Correct answer: B

Rationale: When discontinuing sedative-hypnotic medications, it is crucial to gradually taper them off to prevent withdrawal symptoms. Choice A is incorrect because withdrawal symptoms can be severe, not always mild. Choice C is incorrect as increasing caffeine intake can exacerbate sleep disturbances. Choice D is incorrect because changes in sleep patterns are expected during discontinuation of sedative-hypnotic medications.

5. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?

Correct answer: A

Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.

Similar Questions

During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client’s verbal and nonverbal communication, what action should the RN take?
A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
During an admission assessment and interview, which channels of information communication should the healthcare professional be monitoring? Select all that apply.
To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.
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