NR 326-ATI Mental Health Final Quiz 3

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with 50 Q&A 1. A nurse is planning care for a client who has borderline personality disorder who self-mutilates. Which of the following test approaches should the nurse plan to take? a. Restrict par... ticipation in group therapy sessions. The nurse should encourage the client who has borderline personality disorder to participate in group therapy sessions to encourage appropriate interaction with other clients. b. Establish consequences for self-mutilation. The nurse should respond to self-mutilation with a neutral affect and encourage the client to write down feelings that occurred leading up to the incident. c. Maintain close observation of the client. 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. d. Provide an unstructured environment. Providing an unstructured environment for a client who has borderline personality disorder is not an effective treatment approach because it does not provide a safe environment to protect the client from impulsive and self-injurious behavior. 2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following findings should the nurse expect? a. The client requires assistance with eating. The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability until Stage 7. b. The client independently manages personal finances. The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty performing complex tasks, such as managing personal finances. c. The client has bladder incontinence. The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6. d. The client is able to identify the names of family members. The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and identify family members. Clients who have Alzheimer’s disease maintain this ability until Stage 6. 3. 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 the room is being recorded." Which of the following responses should the nurse make? CONTINUED........ [Show More]

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