A nurse is caring for a client who has borderline personality disorder. Which of the following defense mechanisms is commonly used by clients who have this disorder and has the potential to create division amongst the healthcare team?

Correct Answer: D

Rationale: In the context of caring for a client with borderline personality disorder, the defense mechanism of splitting is commonly observed. Splitting is a coping mechanism where individuals see things as either all good or all bad, failing to integrate both positive and negative qualities into a cohesive whole. This can lead to challenges within the healthcare team as the client may idealize one team member while demonizing another, creating division and discord among the team. Option A, regression, involves reverting to an earlier stage of development in the face of stress. This defense mechanism is not specifically associated with creating division in the healthcare team when compared to splitting in borderline personality disorder. Option B, reaction formation, is when a person exhibits behaviors that are the opposite of their true feelings. While this defense mechanism can impact interactions, it is not typically associated with the significant division that splitting can cause. Option C, denial, involves refusing to acknowledge aspects of reality. While denial can impact treatment adherence and rapport with healthcare providers, it is not as directly linked to creating division among the healthcare team as splitting is in borderline personality disorder. Educationally, understanding defense mechanisms in psychiatric disorders is crucial for nurses to provide effective, empathetic care. By recognizing the impact of splitting in clients with borderline personality disorder, nurses can work to foster collaboration within the healthcare team and mitigate potential conflicts that may arise.

Correct Answer: B

Rationale: In this scenario, the correct nursing diagnosis that would likely apply to both a patient diagnosed with schizophrenia and a patient diagnosed with amphetamine-induced psychosis is option B) Disturbed thought processes. Educational Rationale: 1. **Correct Answer Justification:** Disturbed thought processes are a common symptom in both schizophrenia and amphetamine-induced psychosis. Both conditions can lead to disorganized thinking, delusions, and hallucinations, indicating a disruption in cognitive functioning. 2. **Why Others are Incorrect:** - A) Powerlessness: While powerlessness may be a relevant nursing diagnosis in certain situations, it is not directly associated with the cognitive disturbances seen in schizophrenia and amphetamine-induced psychosis. - C) Ineffective thermoregulation: This option is unrelated to the cognitive symptoms present in both conditions and is more commonly associated with issues related to body temperature regulation. - D) Impaired oral mucous membrane: This option pertains to physical health issues related to the oral cavity and is not directly linked to the cognitive disturbances characteristic of schizophrenia and amphetamine-induced psychosis. 3. **Educational Context:** Understanding the common nursing diagnoses across different psychiatric conditions is crucial for nurses working with patients experiencing mental health issues. By recognizing shared symptoms and appropriate nursing interventions, nurses can provide holistic care tailored to each individual's needs, promoting better patient outcomes and overall well-being.

Correct Answer: A

Rationale: The correct answer is A) Temporary memory impairments and confusion can be associated with electroconvulsive therapy. In this scenario, the patient underwent a significant treatment regimen for major depressive disorder, including electroconvulsive therapy and aggressive medication adjustments. Electroconvulsive therapy can lead to temporary memory impairments and confusion as side effects. Therefore, counseling the patient not to make major decisions for a month is crucial to ensure that they have time to fully recover from these potential cognitive effects. Option B) is incorrect because while antidepressant medications can have side effects, they do not directly impair decision-making abilities by altering catecholamine levels. Option C) is also incorrect as the limitation of tyramine in the diet is more relevant to MAOI medications, not the situation described in the question. Option D) is misleading as it does not address the cognitive effects of the treatment received by the patient. From an educational perspective, understanding the potential side effects of psychiatric treatments is essential for nurses working with patients with mental health disorders. It is important to recognize how different treatments can impact cognitive function and decision-making abilities, and to provide appropriate guidance and support to patients during their recovery process.

Correct Answer: B

Rationale: In the context of treating major depressive disorder, the correct medication that a nurse would likely provide education about is Fluoxetine (Option B). Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression due to its effectiveness in improving mood, appetite, sleep, and energy levels. The other options are not typically used as first-line treatments for major depressive disorder: A) Chlordiazepoxide is a benzodiazepine primarily used for anxiety disorders and not recommended for long-term use in depression due to the risk of dependence and sedation. C) Clozapine is an atypical antipsychotic mainly indicated for treatment-resistant schizophrenia or bipolar disorder with psychosis, not as a first-line option for major depressive disorder. D) Tacrine is a medication used in Alzheimer's disease for cognitive enhancement and is not indicated for major depressive disorder. Educationally, understanding the rationale behind medication choices in psychiatric nursing is crucial for providing safe and effective care to patients. Nurses need to be knowledgeable about the pharmacological mechanisms, indications, side effects, and monitoring parameters of medications to ensure optimal patient outcomes. In the case of major depressive disorder, SSRIs like Fluoxetine are often preferred due to their efficacy and relatively favorable side effect profile compared to other classes of medications.

Correct Answer: D

Rationale: In this scenario, the priority nursing intervention for a patient diagnosed with bulimia nervosa and a low BMI of 17.5 is to assess the patient for signs of self-induced vomiting and purging behaviors (Option D). This intervention is crucial because individuals with bulimia nervosa often engage in these harmful behaviors to control their weight, leading to serious physical and psychological consequences. By identifying and addressing these behaviors promptly, nurses can prevent further health complications and provide appropriate interventions. Option A, monitoring the patient's nutritional intake and weight regularly, is important in the overall management of bulimia nervosa, but it is not the priority when the patient's BMI is critically low. Option B, encouraging the patient to discuss their eating habits openly, may be beneficial for building rapport and trust but does not address the immediate health risks associated with a low BMI. Option C, providing structured meal plans and counseling, is also essential in the long-term treatment of bulimia nervosa but does not address the urgent need to assess and intervene in self-induced purging behaviors. From an educational perspective, understanding the priority of interventions based on the patient's condition and prioritizing immediate health risks in psychiatric nursing is crucial. By focusing on the most critical aspect of care first, nurses can ensure patient safety and well-being in acute situations like this one. The rationale behind choosing the correct intervention should always be grounded in evidence-based practice and an understanding of the specific needs of patients with eating disorders.