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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Correct Answer is B

Explanation

A. Record the client's intake and output every shift: While important for monitoring fluid balance, this intervention does not directly facilitate increased fluid intake.
B. Offer a glass of fluid every hour while awake: This intervention ensures regular and frequent opportunities for the resident to consume fluids, which can help increase overall intake.
C. Increase fluids provided with the client's meals: While this may help increase fluid intake, relying solely on meals may not be sufficient, especially if the resident does not finish their meals.
D. Maintain a full pitcher of water at the bedside: While having water readily available is important, relying solely on this may not ensure regular intake throughout the day.

A. Pull the pinnae up and back to administer the drops. B. Administer the drops with the head held upright. C. Cool and shake the bottle before administering the drops. D. Insert the tip of the dropper into the canal of the ear.

Correct Answer is A

Explanation

A. Pulling the pinnae up and back helps straighten the ear canal in adults, allowing easier administration of the ear drops and better penetration into the ear canal. This technique is appropriate for adults.
B. Administering the drops with the head held upright may be necessary for some ear drop medications, but it is not the most appropriate technique for all types of ear drops.
C. Cooling and shaking the bottle before administering the drops may be necessary for certain types of medications but is not universally recommended for all ear drop preparations.
D. Inserting the tip of the dropper into the canal of the ear is appropriate for administering ear drops, but it should be accompanied by the correct technique of pulling the pinnae up and back to straighten the ear canal in adults.

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Naxlex Comprehensive Predictor Exams

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Correct Answer is B

Explanation

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

Correct Answer is A

Explanation

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?

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Exhibits What should the nurse include in post discharge care education? Select all that apply.

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

Exhibits After the physician orders the echocardiogram, the nurse provides education to the parents on the procedure. For each statement, click to indicate whether the statement by the parents indicate understanding or no understanding. Each row must have only one response option selected.

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?