What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

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HESI Mental Health 2023 Questions

Question 1 of 5

What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

Correct Answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

Question 2 of 5

An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?

Correct Answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.

Question 4 of 5

When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?

Correct Answer: C

Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.

Question 5 of 5

A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important information for the nurse to provide?

Correct Answer: B

Rationale: The correct answer is B: "Report any muscle stiffness or unusual movements immediately." This information is crucial because muscle stiffness or unusual movements may indicate extrapyramidal symptoms (EPS), a potential side effect of risperidone that requires immediate attention. Choice A is less critical as regular blood tests are important but not as urgent as identifying EPS. Choice C is irrelevant as tyramine interactions are not associated with risperidone. Choice D is incorrect as weight gain is more common than weight loss with risperidone.

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