Answers Rated A
A nurse is planning care for a client who has borderline personality disorder who self-mutilates.
Which of the following treatment approaches should the nurse plan to take?
a)Restrict participation in group therapy sessions
b)Establish consequences for self-mutilation
c)Maintain close observation
d) Provide an unstructered environment ✔✔c)Maintain close observation
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
A nurse is caring for a client who has Alzheimer's disease and a new prescription for donepezil.
What action should the nurse take? ✔✔Administer the medication at bedtime.
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 this room is being
recorded." What response should the nurse make? ✔✔"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 nurse-
client relationship.
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder.
What finding should the nurse expect? ✔✔Confusion.
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
A nurse is providing teaching to a client who has generalized anxiety disorder and a new
prescription for buspirone. The nurse should inform the client that which manifestations is a
common adverse effect of this medication? ✔✔Dizziness.
The nurse should inform the client that dizziness is a common adverse effect of buspirone. The
nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.