1. A nurse is planning care for a client who has borderline personality disorder who self
mutilates. Which of the following approaches should the nurse plan to take?
a. Restrict participation in group therapy sessions.
b. Establish consequences for self-mutilation.
c. Maintain close observation of the client.
d. Provide an unstructured environment.
Answer: c. Maintain close observation of the client.
2. A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following
findings should the nurse expect?
a. The client requires assistance with eating.
b. The client independently manages personal finances.
c. The client has bladder incontinence.
d. The client is able to identify the names of family members.
Answer: d. The client is able to identify the names of family members.
3. A nurse is caring for a client who reports that the television set in the room is really a two-way
radio and states, "voices are coming from the TV and everything we say in the room is being
recorded." Which of the following responses should the nurse make?
a. "What we say is not being recorded."
b. "Let's ignore the voices and talk about something else."
c. "That must be very frightening."
d. "Why do you think the TV is a two-way radio?"
Answer: c. "That must be very frightening."