A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

I'll talk to Peter and present your concerns."

I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

Why are you overeacting to the issue

You should bring this to the attention of your treatment team.

Answer and Explanation

The Correct Answer is A

A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.

B. "Why are you overreacting to the issue?"

This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.

C. "You should bring this to the attention of your treatment team."

While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.

D. "I'll talk to Peter and present your concerns."

This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.

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Correct Answer is B

Explanation

A. Using authoritative leadership to help clients learn to conform to societal norms: Authoritative leadership may be perceived as controlling and is unlikely to be effective with clients diagnosed with borderline personality disorder. It can lead to resistance and difficulties in building a therapeutic alliance.

B. Being firm, consistent, and empathetic, while addressing specific client behaviors: This approach is most appropriate. Clients with borderline personality disorder often benefit from clear and consistent boundaries, along with empathy from the nurse. Addressing specific behaviors helps establish a structured and safe therapeutic environment.

C. Promoting client expression by implementing laissez-faire leadership: Laissez-faire leadership, characterized by minimal interference or direction, is generally not suitable for clients with borderline personality disorder. They may struggle with emotional dysregulation and benefit from a more structured and supportive approach.

D. Overlooking inappropriate behaviors to avoid promoting secondary gains: Overlooking inappropriate behaviors may reinforce maladaptive patterns and hinder progress in therapy. It is essential to address and work through specific behaviors while maintaining empathy and consistency.

A. Risk for suicide B. Risk for injury C. Powerlessness D. Risk for imbalance nutrition

Correct Answer is A

Explanation

A. Priority. The patient is exhibiting severe depression, weight loss, and expressing hopelessness, which are all indicators of an increased risk for suicide. Assessing and addressing the risk for suicide is crucial to ensuring the safety and well-being of the patient.

B. Incorrect. While the patient may be at risk for injury due to factors such as poor nutrition and potential self-harm, the immediate concern in this case is the risk for suicide, given the patient's severe depression and expressed hopelessness.

C. Incorrect. Powerlessness may be a relevant nursing diagnosis for individuals experiencing depression, but the immediate concern in this case is the risk for suicide. Addressing the patient's sense of powerlessness can be part of the broader care plan, but it's not the priority.

D. Incorrect. While the patient has experienced significant weight loss, the priority at this time is addressing the risk for suicide. Once the immediate safety concern is addressed, nutritional concerns can be addressed as part of the overall care plan.

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A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

Correct Answer is B

Explanation

A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Correct Answer is A

Explanation

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Thorazine 150mg PO was order for a client. Thorazine is available in 50mg tablets. How many tablets will you administer?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

A nurse is completing an assessment of a client. Which of the following information should the nurse anticipate the provider will use in the diagnosis of a mental health disorder?

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?

A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?