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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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

A. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is indicated for immunocompromised clients, not for MRSA wound infections. It does not reduce transmission or address wound healing.

B. Use standard precautions and wear a mask: Standard precautions are necessary, but a mask is not required for MRSA unless there is risk of aerosolization (e.g., respiratory infection). The key precaution is contact isolation, not routine mask use.

C. Monitor the client’s white blood cell count (WBC): Tracking WBC trends helps identify worsening infection or systemic involvement such as sepsis. This is an important part of managing MRSA.

D. Institute contact precautions for staff and visitors: MRSA is transmitted by direct contact with infected drainage or contaminated surfaces, so gown and glove use with contact precautions are essential.

E. Send wound drainage for culture and sensitivity: Culturing identifies the causative organism and determines antibiotic sensitivity, which guides effective treatment planning.

A. Thirst. B. Increased appetite. C. Heat intolerance. D. Tachycardia. E. Urinary frequency.

Correct Answer is ["A","D","E"]

Explanation

A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.

B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.

C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.

D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.

E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.

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Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["C","D","E"]

Explanation

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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

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