Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms.
The nurse should identify these behaviors as characteristics of which of the following personality disorders?
A. Borderline
Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial
Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Paranoid
Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Histrionic
Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Borderline.
- A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
- B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
- C. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
- D. Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
Similar Questions
A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?
A. Limit suctioning the client's airway to 30 seconds at a time
Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
B. Group several nursing activities to be completed at one time
Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate.
C. Flex the client's neck forward
Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
D. Place the client in a quiet environment
Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
Full Explanation
Place the client in a quiet environment.
- A. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
- B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.
- C. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
- D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?
A. Measuring the group's work against the assigned objectives
Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.
B. Noting the progress of the group toward assigned goals
Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.
C. Sharing experiences as an authority figure
Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.
D. Offering new and fresh ideas on an issue
Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.
Full Explanation
- A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.
- B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.
- C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.
- D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.
A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
A. Hold hands folded below the waist after donning sterile gloves
This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
B. Pick up and pour solutions with the palm of the hand covering bottle labels
This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape
This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
D. Maintain sterile objects within the line of vision
This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.
Full Explanation
Maintain sterile objects within the line of vision.
- A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
- B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
- C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
- D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.