Question

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

Answer 1

Correct Answers:

“I expect you to speak to me in a civil tone of voice."

Rationale :

🟣 Clients with borderline personality disorder (BPD) often display impulsivity, intense emotional reactions, and difficulty regulating anger, which may lead to verbal outbursts.

🟣 This response uses clear limit-setting, a key therapeutic strategy for clients with BPD, by calmly stating behavioral expectations without engaging in confrontation or criticism.

🟣 The nurse maintains professional boundaries while modeling respectful communication, which helps build consistency and structure, crucial for clients with BPD.

🟣 Responding with neutral firmness helps avoid reinforcing manipulative or aggressive behaviors and preserves the therapeutic relationship.

🟣 This approach also promotes self-awareness and accountability, encouraging the client to reflect on their behavior in a non-threatening way.

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Answer 2

Correct Answers:

Offer the client an antianxiety medication.

Rationale :

🔴 When verbal de-escalation fails and the client remains agitated but not yet violent, the next least restrictive and therapeutic intervention is to administer a prescribed antianxiety (anxiolytic) medication.

🔴 Medications such as lorazepam or diazepam can reduce escalating agitation and help prevent the situation from progressing to aggression or violence.

🔴 This action respects the client's autonomy while also protecting safety and avoiding the need for more restrictive measures like seclusion or restraints, which are used only when less invasive methods fail.

🔴 Offering medication also reinforces a collaborative approach to managing emotional dysregulation, a common challenge in mental health settings.

🔴 According to the continuum of behavioral intervention, medication is an appropriate intermediate step before physical interventions.

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Answer 3

Correct Answers:

Offer the client an antianxiety medication.

Rationale :

🔵 When a client is agitated and unable to calm down with verbal de-escalation, the next step is to offer a prescribed antianxiety medication to prevent escalation to physical aggression.

🔵 This approach is consistent with the least restrictive intervention principle, a core value in psychiatric care that prioritizes client dignity and autonomy.

🔵 Medications like benzodiazepines (e.g., lorazepam) can effectively reduce anxiety, agitation, and emotional volatility, helping the client regain control without the need for physical interventions.

🔵 Administering medication before considering seclusion or restraints supports client safety and emotional regulation in a non-confrontational way.

🔵 Therapeutic planning and behavior contracts can follow once the client is calm, but immediate physiological calming is the priority to maintain unit safety.

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Answer 4

Correct Answers:

Set limits on the amount of time the client talks about delusions,

Rationale :

🟣 Clients with schizophrenia and paranoid delusions may fixate on their false beliefs, leading to increased anxiety, mistrust, or agitation if allowed to ruminate excessively.

🟣 Setting time limits for discussing delusions helps redirect focus onto reality-based interactions and activities, which support stabilization and social reintegration.

🟣 The nurse maintains a neutral, non-confrontational approach while gently limiting delusional conversations to reduce reinforcement of psychotic thought patterns.

🟣 This intervention fosters structure, predictability, and emotional safety, all of which are essential for clients with thought disorders.

🟣 After time limits are set, the nurse can redirect the conversation toward more goal-oriented or therapeutic content, promoting recovery.

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Answer 5

Correct Answers:

"I should sit on the side of the bed before standing up in the morning

Rationale :

🔵 Amitriptyline (Elavil) is a tricyclic antidepressant (TCA) that can cause orthostatic hypotension, especially during treatment initiation.

🔵 Sitting on the edge of the bed before standing is a safety measure to prevent dizziness, lightheadedness, and falls due to sudden blood pressure drops.

🔵 TCAs also have anticholinergic side effects such as dry mouth, blurred vision, and urinary retention, but orthostatic hypotension is one of the most common early effects.

🔵 Educating clients on position changes promotes safety and demonstrates an understanding of how to minimize adverse effects.

🔵 This precaution is especially important in older adults, who are more susceptible to TCA-induced hypotension and injuries from falls.

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Answer 6

Correct Answers:

"I should sit on the side of the bed before standing up in the morning

Rationale :

🔷 Amitriptyline, a tricyclic antidepressant (TCA), is well known to cause orthostatic hypotension, particularly when initiating treatment or increasing the dose.

🔷 Teaching the client to rise slowly from lying or sitting positions—such as sitting on the side of the bed first—helps prevent dizziness and falls due to sudden drops in blood pressure.

🔷 This practice supports safety and independence, especially important in older adults or clients with balance issues.

🔷 While other side effects of TCAs include dry mouth, sedation, and weight gain, orthostatic hypotension is often the most immediate safety risk.

🔷 Reinforcing this understanding demonstrates effective client education and self-care planning for managing medication side effects.

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Answer 7

Correct Answers:

"What are the voices telling you to do?"

Rationale :

🔴 The priority in this situation is safety, and the nurse must assess whether the auditory hallucinations involve commands to harm self or others (command hallucinations).

🔴 Asking "What are the voices telling you to do?" is a therapeutic and nonjudgmental approach that helps gather critical information while supporting the client emotionally.

🔴 This response allows the nurse to assess the level of risk, initiate appropriate precautions if needed, and involve the healthcare team quickly if danger is present.

🔴 It also demonstrates active listening and empathy, showing the client that their experience is being taken seriously without reinforcing the hallucination.

🔴 After assessing for safety, the nurse can implement strategies such as reality orientation, medication compliance support, or referral to crisis services if necessary.

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Answer 8

Correct Answers:

"Til stay with you for a few minutes."

Rationale :

🟣 This response demonstrates therapeutic presence, which is a powerful form of support for clients experiencing emotional distress.

🟣 By staying quietly with the client, the nurse conveys empathy, acceptance, and availability without pressuring the client to speak.

🟣 It helps build trust and emotional safety, especially in clients with depression or emotional withdrawal, who may fear rejection or judgment.

🟣 This approach respects the client’s need for space while still offering compassionate support, a foundational aspect of mental health nursing.

🟣 It also opens the door for the client to speak when ready, fostering emotional expression at the client’s pace.

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Answer 9

Correct Answers:

Potassium 2.8 mEq/L

Rationale :

🔴 Hypokalemia (low potassium) is a life-threatening complication of bulimia nervosa, especially due to vomiting, laxative abuse, or diuretic use.

🔴 A potassium level of 2.8 mEq/L is critically low and places the client at high risk for cardiac arrhythmias, muscle weakness, and respiratory depression.

🔴 In clients with eating disorders, electrolyte imbalances must be corrected immediately to prevent cardiac arrest or sudden death.

🔴 This is the nurse’s top priority because it directly impacts circulation and cardiac conduction, placing it above other abnormal but less emergent findings.

🔴 Treatment typically includes IV potassium replacement and cardiac monitoring, and must be initiated urgently.

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Answer 10

Correct Answers:

Projection

Rationale :

🔴 Projection is a defense mechanism in which an individual attributes their own feelings, thoughts, or impulses to others, often to avoid facing them directly.

🔴 In this scenario, the client projects their own anger and desire to drink onto the staff, suggesting that they feel what he actually feels.

🔴 This is common in clients struggling with addiction and denial, as it helps them externalize blame and avoid taking responsibility for their behavior.

🔴 Projection can be a barrier to therapeutic engagement and must be addressed with non-confrontational strategies, such as promoting self-awareness and reflection.

🔴 Recognizing projection helps nurses respond therapeutically without reinforcing distorted perceptions.

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QLexNursing

2 :
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

3 :
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

4 :
A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

5 :
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

6 :
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

7 :
A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

8 :
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

9 :
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

10 :
A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

QLexNursing

2 : A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

3 : A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

4 : A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

5 : A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

6 : A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

7 : A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

8 : A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

9 : A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

10 : A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

2 :
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

3 :
A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

4 :
A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

5 :
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

6 :
A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

7 :
A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

8 :
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

9 :
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

10 :
A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?