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?"

Answer and Explanation

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.

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Free Nursing Study Resources

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

Explanation

A. Shaking that changes the child's handwriting legibility could indicate a neurological or motor issue and warrants further assessment by the school nurse.
B. Bruises on both knees after the weekend are likely minor and do not typically require immediate referral to the school nurse unless there are other concerning signs of abuse or injury.

C. Sunburn with blisters on the face, arms, and hands could indicate severe sunburn and potential complications such as infection or dehydration, requiring evaluation by the school nurse.
D. Refusing to complete written homework assignments may indicate behavioral issues or difficulties with learning but does not necessarily require immediate referral to the school nurse.

E. Thirst and frequent requests for bathroom breaks could indicate underlying medical issues such as diabetes or urinary tract infection and should be reported to the school nurse for further assessment.

A. Obtain a 12-lead electrocardiogram daily. B. Monitor and document strict intake and output. C. Assess the serum potassium level every 4 hours. D. Evaluate glucose levels before and after meals.

Correct Answer is C

Explanation

A. While monitoring the client’s cardiac status is important due to the risk of arrhythmias with hyperkalemia, obtaining a daily ECG is not the most immediate or frequent evaluation required. Continuous cardiac monitoring is typically preferred in such cases.

B. Monitor and document strict intake and output: While important for overall fluid balance, this option does not specifically address the potential cardiac complications associated with hyperkalemia and insulin administration.
C. The prescribed treatment involves insulin, which facilitates the movement of potassium into cells, thereby reducing serum potassium levels. Monitoring potassium frequently is essential to evaluate the treatment’s effectiveness and to prevent hypokalemia, which can lead to complications such as arrhythmias or muscle weakness.

D. Evaluate glucose levels before and after meals: Monitoring glucose levels is important for diabetes management but does not address the immediate cardiac risks associated with
hyperkalemia and insulin administration.

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Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

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

Explanation

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Exhibits Which interventions are indicated to promote positive outcomes for the client? Select all that apply.

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.