Correct Answer: A

Rationale: Fear of abandonment is a hallmark symptom of borderline personality disorder, driving intense emotional reactions and unstable relationships.
Choice B is incorrect because a persistent sad mood is more associated with depression, not borderline personality disorder, which involves mood instability.
Choice C is incorrect because recurrent intrusive memories are characteristic of PTSD, not borderline personality disorder.
Choice D is incorrect because hypersomnia is not typical; sleep disturbances may occur but are not a primary feature.

Correct Answer: A,B

Rationale: Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client's medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer's solution are not indicated nursing actions for the client. Explanation: Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client's vital signs and symptoms closely. Documenting the blood product transfusion in the client's medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion. Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after. Titrating the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload: This may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client's condition, weight, and response to the transfusion, not on a fixed target. Starting an IV bolus of lactated Ringer's solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Correct Answer: C

Rationale: Crackles in bilateral lung bases indicate fluid accumulation or infection in the lungs, a concerning finding in pneumonia that may suggest worsening condition or complications like pulmonary edema, requiring immediate reporting.
Choice A is incorrect because an oxygen saturation of 92% is borderline but not immediately alarming in pneumonia, especially if the client is receiving oxygen; it should be monitored.
Choice B is incorrect because a respiratory rate of 24/min is slightly elevated but expected in pneumonia and not the priority to report.
Choice D is incorrect because a temperature of 37.8°C is a low-grade fever, common in pneumonia, and does not require immediate reporting unless persistent or accompanied by other symptoms.

Correct Answer: D

Rationale: Monitoring for signs of serotonin syndrome (e.g., agitation, tremors, hyperthermia) is critical with fluoxetine, an SSRI, as it increases serotonin levels, and overdose or drug interactions can cause this life-threatening condition.
Choice A is incorrect because fluoxetine is typically taken in the morning, but this is not the priority instruction compared to safety monitoring.
Choice B is incorrect because fluoxetine takes 4-6 weeks to reduce OCD symptoms, not immediate relief.
Choice C is incorrect because fluoxetine should not be discontinued abruptly, even if compulsions stop, to avoid withdrawal or relapse; it requires provider guidance.

Correct Answer: C

Rationale: Discussing with the client his inappropriate behavior prior to seclusion is important, but it's not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client's behavior prior to seclusion. Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context. Documenting the client's behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention. Assessing the client's behavior once every hour is important to monitor the client's condition and response to seclusion. However, this is not the most appropriate action in this context.