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 selfharm 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