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 D

Explanation

A. The client will monitor blood glucose and blood pressure after each meal: While monitoring blood pressure may be important for cardiovascular health, this outcome specifically addresses blood glucose, which may not be directly related to the client's newly diagnosed cardiovascular disease.
B. The client's blood pressure readings will be less than 160/90 mm Hg: This outcome focuses on blood pressure control, but the goal of less than 160/90 mm Hg may not be stringent enough for optimal cardiovascular health.
C. The nurse will encourage the client to walk thirty minutes every day: Exercise is important for cardiovascular health, but this outcome does not specifically address blood pressure
management, which is crucial for reducing the risk of cardiovascular events.
D. The client's daily blood pressure will be less than 140/80 mm Hg this month: This outcome addresses blood pressure control, setting a specific target (less than 140/80 mm Hg) that aligns with current guidelines for managing cardiovascular disease and reducing the risk of
complications.

A. Match ID bands of all infants and mothers on the unit. B. Determine if the newborn is in the nursery. C. Ask the mother if any visitors were expected to arrive. D. Activate the lockdown procedure.

Correct Answer is D

Explanation

A. Matching ID bands of all infants and mothers on the unit is an important step in ensuring infant safety and preventing mix-ups. However, this action does not address the immediate need to secure the facility and prevent the potential abduction of the newborn.

B. Determining if the newborn is in the nursery is important, but it is not the first priority. The nurse must act immediately to secure the unit and prevent the possibility of the infant being removed from the hospital.

C. Asking the mother if any visitors were expected may provide helpful information, but it is not the first action. The priority is to ensure the safety of all infants and prevent unauthorized exits from the facility.

D. Activating the lockdown procedure is the first and most critical action. This ensures that all exits are secured, preventing the potential abductor from leaving the facility. Once the lockdown is in place, the nurse can proceed with further actions to locate the infant and investigate the situation.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

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After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

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The healthcare provider prescribes heparin 3 units/kg IV push for a client who weighs 175 pounds. The vial is labeled, "100 units/mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth).