Correct Answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

Correct Answer: A

Rationale: In cognitive-behavioral therapy (CBT), one of the primary objectives is to help clients identify and challenge their negative thoughts. This process allows the individual to reframe their thinking patterns and develop more adaptive coping strategies. Reporting an increase in suicidal thoughts (Choice B) or experiencing an increase in anxiety (Choice C) are not desired outcomes and may indicate a need for further intervention. Showing no change in behavior (Choice D) suggests that the therapy has not been effective. Therefore, the correct indicator of effective therapy in this context is the client's ability to identify and challenge negative thoughts (Choice A).

Correct Answer: C

Rationale: When a client with major depressive disorder expresses feelings of hopelessness, helping them identify positive aspects of their life can be an effective nursing intervention. This approach can assist in shifting their focus from negativity to positivity, promoting a sense of hope and potentially improving their overall outlook and well-being. By highlighting the positive aspects, the nurse can support the client in recognizing reasons for hope and encourage a more optimistic perspective, which can aid in addressing and alleviating feelings of hopelessness. Encouraging physical activity (Choice A) may be beneficial for overall well-being but may not directly address feelings of hopelessness. Providing opportunities for decision-making (Choice B) can empower the client but may not specifically target feelings of hopelessness. Encouraging verbalization of feelings (Choice D) is important but may not be as effective as helping the client shift their focus to positive aspects of life.

Correct Answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.

Correct Answer: B

Rationale: When a client with schizophrenia is experiencing delusions, providing reality-based feedback is considered an effective intervention to address this symptom. This approach helps the client differentiate between what is real and what is not real, assisting them in managing their delusions and promoting their overall well-being. Choice A is incorrect because ignoring the delusions does not help the client in distinguishing reality from delusions. Choice C is incorrect as distraction may only provide temporary relief but does not address the underlying issue. Choice D is incorrect because encouraging the client to discuss the delusions may reinforce or intensify them rather than help in managing them effectively.