a nurse is developing a care plan for a patient with borderline personality disorder which intervention should be included to address self harm behavi
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Nursing Elites

ATI LPN

ATI Mental Health Practice A 2023

1. When developing a care plan for a patient with borderline personality disorder, which intervention should be included to address self-harm behaviors?

Correct answer: D

Rationale: Developing a safety plan with the patient is crucial when addressing self-harm behaviors in individuals with borderline personality disorder. This intervention helps outline steps to take during a crisis, identifies triggers, and provides strategies to prevent self-harm incidents. It involves collaboratively creating a plan between the patient and the healthcare team to ensure a structured and supportive approach to managing potentially dangerous situations.

2. During a mental health assessment, a patient states, 'I just don't see the point in anything anymore.' This statement is an indication of which of the following?

Correct answer: C

Rationale: The patient's statement 'I just don't see the point in anything anymore' reflects feelings of hopelessness and a lack of purpose, which are common symptoms of depression. Depression is characterized by persistent feelings of sadness, emptiness, and loss of interest or pleasure in activities that were once enjoyable. While anxiety disorders can involve excessive worry and fear, bipolar disorder includes episodes of both depression and mania, and schizophrenia typically involves symptoms such as hallucinations and delusions. Therefore, depression is the most appropriate choice based on the patient's statement.

3. A patient is receiving education about taking clozapine. Which statement indicates the patient understands the side effects?

Correct answer: A

Rationale: The correct answer is A because patients taking clozapine should report signs of infection immediately due to the risk of agranulocytosis. Agranulocytosis is a potentially life-threatening side effect of clozapine characterized by a significant decrease in white blood cell count, which can leave the patient vulnerable to infections. Reporting signs of infection promptly is crucial to prevent serious complications.

4. Which symptom is most characteristic of generalized anxiety disorder (GAD)?

Correct answer: B

Rationale: Excessive worrying about various aspects of life is a hallmark symptom of generalized anxiety disorder (GAD). In GAD, individuals experience excessive and uncontrollable worry about a wide range of everyday problems. This persistent worrying can lead to physical and emotional symptoms, impacting their daily functioning and quality of life. Fear of social situations, hallucinations, and impulsive behaviors are not typically associated with GAD.

5. What principle should guide a nurse's fear about 'saying the wrong thing' to a patient in nurse-patient communication?

Correct answer: A

Rationale: Effective nurse-patient communication is guided by the principle that patients value sincere and respectful interactions. A nurse's well-meaning approach that conveys acceptance, respect, and concern helps establish trust and rapport with patients, even if the nurse is apprehensive about making mistakes. It is essential for the nurse to focus on genuine intent and respect for the patient's situation rather than being consumed by the fear of saying something wrong.

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