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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Questioning the client about the frequency of falls in recent months is an essential component of a functional assessment, especially for an older adult being admitted to a rehabilitation facility.
Understanding the history of falls helps identify potential risk factors and informs the development of an appropriate care plan.
B. Asking the client how often episodes of sundowning are experienced is not relevant to a functional assessment. Sundowning refers to increased confusion and agitation that typically occurs in the late afternoon or evening and is often associated with dementia.
C. Assisting the client with values clarification about end-of-life care options is important but not typically part of a functional assessment focused on evaluating the client's physical and cognitive abilities.
D. Encouraging the client to lie as still as possible during the assessment may not provide accurate information about the client's functional status. It's important for the client to engage in activities that reflect their typical level of functioning.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B","dropdown-group-3":"A"}
Explanation
- The initial blood gas results show a pH of 7.21, which is below the normal range, indicating acidosis.
- The PaCO2 is elevated at 58 mmHg, suggesting that the acidosis is respiratory in nature, as CO2 is a respiratory acid.
- The HCO3 level is within the normal range, which typically would not suggest a primary metabolic problem.
- The repeat blood gas shows an improvement in pH to 7.37, which is within the normal range, indicating that the condition is being compensated.
- The PaCO2 has decreased to 52 mmHg, which is still above normal but shows improvement, further supporting the compensation.
- Given these changes, the most likely interpretation of the blood gas results is that the client has "compensated respiratory acidosis."
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