Correct Answer: A

Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (
Choice
B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (
Choice
C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (
Choice
D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.

Correct Answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

Correct Answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect.
Therefore, the client should be advised to avoid direct sun exposure.
Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge.

Choices B, C, and D demonstrate accurate knowledge.
Choice B is important because alcohol can interact with Prolixin.
Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin.
Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

Correct Answer: D

Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (
Choice
A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (
Choice
B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (
Choice
C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.

Correct Answer: B

Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (
Choice
A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (
Choice
C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (
Choice
D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.