The nurse is assessing a client who is diagnosed with borderline personality disorder. Which client statement indicates the client is at risk for self-injurious behavior?

Correct Answer: D

Rationale: The correct answer is D because impulsivity is a common characteristic of borderline personality disorder and can lead to self-injurious behaviors. The statement "It is almost as if as soon as I think of doing something, I immediately do it" indicates a lack of impulse control and potential for engaging in harmful behaviors without considering consequences. A: This statement expresses feelings of depression but does not directly indicate self-injurious behavior risk. B: This statement suggests a lack of autonomy but does not directly indicate self-injurious behavior risk. C: This statement describes dissociation, which is common in borderline personality disorder but does not directly indicate self-injurious behavior risk. In summary, choice D is the correct answer as it directly implies impulsivity and potential for self-injurious behavior, while the other choices do not clearly indicate this risk.

Correct Answer: C

Rationale: Step 1: The correct answer is C because it indicates a prolonged period of over 2 months of persistent symptoms such as crying, inability to eat or sleep. Step 2: This prolonged duration of symptoms is indicative of a potential depressive episode. Step 3: The inability to eat or sleep are common symptoms of depression. Step 4: This statement highlights a significant change in the father's behavior following the mother's death, suggesting a possible depressive disorder. Summary: Choice A: The duration of symptoms is not as prolonged as in choice C. Choice B: While agitation and anxiety can be symptoms of depression, they are not as specific or severe as the symptoms in choice C. Choice D: The timeframe of symptoms mentioned here is not as long as in choice C, making it less concerning for depression.

Correct Answer: B

Rationale: The correct answer is B, recognizing the signs of danger, as it is crucial to be able to identify potential threats before devising an escape plan or identifying safe places. By recognizing signs of danger, the client can proactively assess risky situations and take necessary precautions. This step is vital in ensuring the client's safety and preventing harm. Option A, devising an escape route, would be ineffective if the client cannot recognize the signs of danger to know when to use the route. Option C, identifying a safe place to hide, is not as effective as recognizing signs of danger since hiding may not always be a viable solution. Option D, identifying a signal to indicate it is safe to leave, would not be effective if the client cannot accurately assess when it is safe to leave. Recognizing signs of danger is the foundational step in creating a comprehensive safety plan.

Correct Answer: A

Rationale: The correct answer is A: Draw a troponin level every four hours. Troponin levels are important indicators of myocardial infarction. Drawing troponin levels every four hours allows the nurse to closely monitor the client's cardiac enzyme levels for any signs of ongoing myocardial damage. This frequent monitoring helps in early detection of complications and guides further treatment decisions. Explanation for why the other choices are incorrect: B: Performance EKG every 12 hours - While EKG monitoring is important in assessing cardiac function, performing it every 12 hours may not be as frequent as needed in the acute phase post-myocardial infarction. C: Plant oxygen tent fell over minutes via rebreather mask - This intervention does not directly address the client's recovery from myocardial infarction and is not a standard post-MI care measure. D: Obtain a cardiac rehabilitation consult - While cardiac rehabilitation is essential for long-term recovery, it is not a point-of-care intervention immediately post-my