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."
"What did the night nurse do that makes you think the nurse is aloof?"
"I am glad you like me. Which nurse was acting aloof to you?"
The Correct Answer is C
A. "I am happy that you are getting better and will be able to go home.": While positive reinforcement is supportive, it does not address the client’s dichotomous thinking or help them process their perception of the night nurse. It avoids exploring the issue.
B. "Tomorrow I will talk to that nurse about how you were treated last night.": This response reinforces splitting behavior by positioning the nurse as an advocate against a colleague, which may escalate the client’s polarized thinking.
C. "What did the night nurse do that makes you think the nurse is aloof?": This approach encourages the client to reflect on specific behaviors rather than labeling individuals. It helps the client develop insight, reduces dichotomous thinking, and promotes accountability for their perceptions.
D. "I am glad you like me. Which nurse was acting aloof to you?": Combining affirmation with comparison may unintentionally reinforce splitting and favoritism, maintaining the client’s black-and-white perception of others. It does not encourage reflective thinking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Calculation:
- Convert the client's weight from pounds (lb) to kilograms (kg).
The client's weight is 154 lb.
Client weight (kg) = 154lb/2.2lb/kg
= 70kg.
- Calculate the total dose to be administered (units).
The ordered dose is 200 units/kg.
Total dose (units) = 200units/kg×70kg
= 14,000units.
- Calculate the volume to administer in milliliters (mL).
Available concentration is 25,000units/mL.
Volume (mL) = Totaldose(units)/Availableconcentration(units/mL)
= 14,000units/25,000units/mL
= 0.56mL.
- Round the answer to the nearest tenth.
= 0.6mL.
Correct Answer is A
Explanation
A. Assess the level of consciousness and vital signs for both clients: Assessing vital signs and mental status identifies immediate changes in condition, particularly in critically ill clients. This is a priority because it helps detect life-threatening complications early.
B. Review the plan of care and the medications that are due for both clients: While important for planning interventions, reviewing the plan does not address immediate client safety and physiological status, which takes priority.
C. Complete a head-to-toe assessment of the client with pneumonia: A comprehensive assessment is valuable, but initial priority is rapid evaluation of vital signs and consciousness to identify urgent issues in the mechanically ventilated client.
D. Change the surgical dressing to observe the appearance of the incision: Dressing changes are important for infection prevention, but they are not emergent unless there are signs of acute bleeding or infection. Immediate physiologic assessment takes precedence.
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