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 ["A","B","C","D","E"]

Explanation

A. Complete blood count: A CBC is essential to evaluate hemoglobin and hematocrit levels, which can indicate the severity of blood loss from abdominal trauma. It also helps monitor for anemia or infection risk in this critical setting.

B. Arterial blood gas: An ABG provides information about oxygenation, ventilation, and acid–base balance, which are crucial for a trauma client on mechanical ventilation. It guides adjustments in ventilator settings and assesses for shock-related metabolic acidosis.

C. Type and screen: Given the evidence of internal bleeding and hypotension, a blood transfusion may be necessary. A type and screen ensures blood products can be matched and made available quickly in case of massive transfusion.

D. Coagulation studies: Trauma and massive transfusion can lead to coagulopathy. PT, INR, and aPTT results help guide interventions such as plasma or platelet administration, ensuring proper clotting function during surgery and recovery.

E. Electrolytes: Monitoring electrolytes is important because fluid resuscitation, blood loss, and shock can cause significant imbalances, such as hypokalemia or metabolic derangements, which can complicate management.

F. Blood culture: Blood cultures are obtained when infection or sepsis is suspected. This client’s presentation is acute trauma-related hemorrhage, not infection, so this test is not immediately useful.

G. Urine osmolality: This test is used to evaluate renal concentrating ability and fluid balance, but it is not a priority in acute trauma. Immediate fluid and blood replacement are the focus.

H. Lipid panel: A lipid panel assesses long-term cardiovascular risk, not acute trauma or hemorrhage. It has no role in the immediate plan of care for this client.

A. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet. B. Encourage him to find activities to do with his friends that do not involve eating. C. Advise him to take his own food with him when going to fast food restaurants with his friends. D. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

Correct Answer is D

Explanation

A. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet: Restricting social activities can lead to feelings of isolation and negatively affect adherence. It does not teach the adolescent practical skills for managing diabetes in real-life situations.

B. Encourage him to find activities to do with his friends that do not involve eating: While alternative activities are beneficial, avoiding meals with friends is not realistic for a teen. The goal is to promote self-management skills, not complete avoidance of social situations.

C. Advise him to take his own food with him when going to fast food restaurants with his friends: Bringing food may help in some situations, but it does not encourage the adolescent to make informed choices or learn how to navigate typical social eating environments.

D. Assist him in identifying popular fast foods that are within his meal plan for diabetes: Teaching the teen how to select appropriate options from common fast food menus empowers him to adhere to his diet while maintaining social interactions. This approach promotes self-management, independence, and realistic coping strategies.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

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

Explanation

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

Correct Answer is D

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

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?

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.