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?"

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Temperature: While monitoring temperature is part of routine assessment, it does not directly affect the safe administration of morphine. Fever is not an immediate contraindication to opioid use.

B. Heart rate: Heart rate should be monitored, but morphine primarily depresses the respiratory system rather than significantly affecting heart rate in most cases.

C. Respiratory rate: Morphine can cause respiratory depression, especially in opioid-naive or older adults. Assessing the respiratory rate before administration ensures the client can safely tolerate the medication and allows for early detection of adverse effects.

D. Blood pressure: Morphine can cause hypotension, so blood pressure monitoring is important, but respiratory depression poses a more immediate life-threatening risk and takes priority before administration.

A. Encourage the wife to voice her feelings about having a husband with Parkinson's disease. B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism. C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease. D. Compile a list of alternative medications that are effective in curing Parkinson's disease.

Correct Answer is C

Explanation

A. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While it is important to provide emotional support and encourage expression of feelings, this does not address her specific question about alternative or complementary cures.

B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: Referring to the neurologist may seem appropriate, but it avoids answering the wife’s concern directly.

C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: Parkinson’s is a progressive neurodegenerative disorder, and while medications and some therapies can manage symptoms, no cure currently exists. This response provides clear, evidence-based information and directly answers the wife’s question.

D. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or complementary medications have been proven to cure Parkinson’s disease. Providing such a list would give false hope and misinformation.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

Correct Answer is C

Explanation

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

Correct Answer is C

Explanation

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?