A client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by claiming the night shift nurse is aloof and expresses joy to see that, "My favorite nurse is on duty now." Which response is best for the nurse to provide to this client's dichotomous tendency?
"I am happy that you are getting better and will be able to go home."
"Tomorrow I will talk to that nurse about how you were treated last night."
"I am glad you like me. Which nurse was acting aloof to you?"
"What did the night nurse do that makes you think the nurse is aloof?"
The Correct Answer is A
A. "I am happy that you are getting better and will be able to go home."
This response focuses on the client’s progress and avoids engaging with their polarized views. It provides positive reinforcement and shifts the focus toward recovery.
B. "Tomorrow I will talk to that nurse about how you were treated last night."
This could escalate the situation and may inadvertently validate the client's idealization or devaluation of others, without fully understanding the dynamics.
C. "I am glad you like me. Which nurse was acting aloof to you?"
This response reinforces the client’s idealization of the current nurse, which could perpetuate dichotomous thinking.
D. "What did the night nurse do that makes you think the nurse is aloof?"
This invites the client to focus on negative perceptions of the night nurse, potentially escalating their emotional instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Blood urea nitrogen (BUN) is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections. It is more commonly monitored to assess renal function and hydration status.
B. White blood cell (WBC count is monitored to evaluate the body's response to infection and the effectiveness of antibiotic therapy. A decrease in the WBC count can indicate resolution of the infection.
C. Red blood cell (RBC count is not directly related to the evaluation of antibiotic effectiveness in treating respiratory tract infections.
D. Urinalysis is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections unless there are specific indications of urinary tract involvement.
E. Sputum culture and sensitivity testing is important to identify the causative organism of the respiratory tract infection and determine its susceptibility to antibiotics. Monitoring the results of sputum culture and sensitivity helps ensure appropriate antibiotic selection.
F. Serum potassium levels may be monitored for clients receiving certain antibiotics, such as some types of penicillins or fluoroquinolones, due to the potential for electrolyte disturbances.
However, it is not a direct measure of antibiotic effectiveness in treating respiratory tract infections.
Correct Answer is ["C","E","F"]
Explanation
A. Typically, there is no need to restrict a child to clear liquids for several days post-cardiac catheterization unless specified by the physician.
B. Bathing should be avoided if the catheterization was done through the groin, but showers are usually permitted after 24 hours, provided the water does not directly hit the incision site.
C. Monitoring for fever is important as it can be a sign of infection.
D. A pressure dressing is usually kept on the site for the first few hours post-procedure, not for an entire week.
E. Ibuprofen can be given for pain, but it's important to follow the physician's advice regarding dosage and frequency.
F. It is crucial to alert the physician if the site bleeds or swells as this could indicate a complication from the procedure.
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