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 participation 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?

a. "What we say is not being recorded."

The nurse should avoid negating the client’s beliefs about the delusion. This response can promote a

defensive client response and interfere with the development of trust in the nurse-client relationship.