Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
Medical History: Borderline personality disorder.Alcohol use disorder.
History of suicidal ideation.
Medication Administration Record: Fluoxetine 20 mg PO daily.
Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.
Client reports recent breakup of romantic relationship and subsequent job loss.
States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.ÔÇØ. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.
Client states, "I feel so alone.
There is no one that cares about me.ÔÇØ. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
Rationale
Encouraging feelings (D) and consistent staff (E) are anticipated. Tyramine avoidance (A) is for MAOIs, restraints (B) are a last resort, and sympathy to maladaptive behavior (C) reinforces negativity.