Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has borderline personality disorder (BPD).
Check the 6 assessment findings that require immediate follow-up:.
A. Financial situation.
Financial instability is a suicide risk factor in clients with BPD, especially when combined with impulsivity, substance use, and recent bereavement. It requires urgent psychosocial and safety evaluation.
B. Increased use of mood-altering substances.
Increased use of mood-altering substances is a serious concern. The client has been drinking heavily and asking for their “nerve” pill, which could indicate substance misuse.
C. Sexual behaviors.
The client’s sexual behaviors, specifically having multiple partners and not using condoms, pose a risk for sexually transmitted infections.
D. Hepatitis Viral Study (HAA) results.
The positive Hepatitis Viral Study (HAA) indicates the presence of a viral hepatitis infection, which requires immediate medical attention.
E. BUN level.
The BUN level is within the normal range (10 to 20 mg/dL), so it does not require immediate follow-up.
F. Hgb level.
The Hgb level is within the normal range (12 to 18 g/dL), so it does not require immediate follow-up.
G. Sodium level.
The sodium level is below the normal range (136 to 145 mEq/L), indicating hyponatremia, which requires immediate medical attention.
H. Being admitted frequently
Frequent admissions suggest chronic instability but are not acutely life-threatening. It warrants care plan review but not immediate emergency follow-up.
I. Recent loss of a parent
The recent loss of a parent is a significant life event that could exacerbate the client’s mental health issues and substance misuse, requiring immediate follow-up.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Custom Nurs 120 Psychiatric Nursing Fa23 Proctored Exam 2. Take the full exam now
Similar Questions
A nurse is caring for a client in an outpatient clinic.
The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).
A. Anxiety.
Anxiety is a common symptom of somatic symptom disorder, as patients often experience significant distress about their physical symptoms.
B. Gastrointestinal distress.
Gastrointestinal distress, such as stomach pain and diarrhea, can be manifestations of somatic symptom disorder. These symptoms can cause significant distress and disrupt daily life.
C. Pain.
Pain, especially when it is not linked to a clear physical cause, can be a symptom of somatic symptom disorder. The distress caused by the pain is often out of proportion to its severity.
D. Bipolar disorder.
Bipolar disorder is a separate mental health condition and is not a symptom of somatic symptom disorder.
E. Fixation on health.
Fixation on health, particularly an excessive preoccupation with physical symptoms, is a key feature of somatic symptom disorder.
F. Depression.
Depression can often co-occur with somatic symptom disorder, as the distress and disruption caused by the physical symptoms can lead to feelings of sadness and hopelessness.
G. Localized amnesia.
Localized amnesia is not a symptom of somatic symptom disorder. It is more commonly associated with other mental health conditions, such as dissociative disorders.
Full Explanation
Choice A rationale:
Anxiety is a common symptom of somatic symptom disorder, as patients often experience significant distress about their physical symptoms.
Choice B rationale:
Gastrointestinal distress, such as stomach pain and diarrhea, can be manifestations of somatic symptom disorder. These symptoms can cause significant distress and disrupt daily life.
Choice C rationale:
Pain, especially when it is not linked to a clear physical cause, can be a symptom of somatic symptom disorder. The distress caused by the pain is often out of proportion to its severity.
Choice D rationale:
Bipolar disorder is a separate mental health condition and is not a symptom of somatic symptom disorder.
Choice E rationale:
Fixation on health, particularly an excessive preoccupation with physical symptoms, is a key feature of somatic symptom disorder.
Choice F rationale:
Depression can often co-occur with somatic symptom disorder, as the distress and disruption caused by the physical symptoms can lead to feelings of sadness and hopelessness.
Choice G rationale:
Localized amnesia is not a symptom of somatic symptom disorder. It is more commonly associated with other mental health conditions, such as dissociative disorders.
A nurse is caring for a client who has schizophrenia.
Nurses' Notes: Day 1 1030: A 35-year-old client who has schizophrenia is admitted.
Diagnosed 15 years ago.
Brought in by partner and states client has remained in room for the last several days and movements are delayed.
Day 1 1730: Client refuses to eat or drink.
Client appears withdrawn and does not engage in conversation.
Client has flat affect.
Does not want to go to therapy session and wants to sleep.
Client's movements are slow.
Vital Signs: Day 1 1030: Temperature 37° C (98.6° F). Heart rate 72/min.
Respiratory rate 20/min.
Blood pressure 132/38 mm Hg. Oxygen saturation: 99% on room air.
Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia:.
A. Withdrawn.
Being withdrawn is a negative symptom of schizophrenia. It refers to the lack of social engagement and reduced interest in others.
B. Lack of energy.
Lack of energy, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
C. Change in behavior.
Change in behavior is too broad to be considered a specific negative symptom of schizophrenia. Both positive and negative symptoms of schizophrenia can lead to changes in behavior.
D. Lack of motivation.
Lack of motivation, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
E. Blood pressure.
Blood pressure is not a symptom of schizophrenia. It is a physiological measurement and does not reflect the psychological symptoms of schizophrenia.
Full Explanation
Choice A rationale:
Being withdrawn is a negative symptom of schizophrenia. It refers to the lack of social engagement and reduced interest in others.
Choice B rationale:
Lack of energy, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
Choice C rationale:
Change in behavior is too broad to be considered a specific negative symptom of schizophrenia. Both positive and negative symptoms of schizophrenia can lead to changes in behavior.
Choice D rationale:
Lack of motivation, or avolition, is a negative symptom of schizophrenia. It refers to a decrease in the initiation and persistence of goal-directed activities.
Choice E rationale:
Blood pressure is not a symptom of schizophrenia. It is a physiological measurement and does not reflect the psychological symptoms of schizophrenia.
Medical History: Borderline personality disorder.
Alcohol use disorder.
History of suicidal ideation.
Medication Administration Record: Fluoxetine 20 mg PO daily.
Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.
Client reports recent breakup of romantic relationship and subsequent job loss.
States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.
Client states, "I feel so alone.
There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
A. Instruct the client to avoid foods with tyramine.
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
B. Apply wrist restraints.
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
C. Offer sympathy and attention to maladaptive behavior.
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
D. Encourage the client to talk about feelings prior to maladaptive behavior.
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
E. Maintain same staff members caring for the client.
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Full Explanation
Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.