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. Assisting the client to recall everyone possibly exposed since the onset of symptoms is important for contact tracing but is not the most immediate action to take.
B. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for infection control but does not address the immediate need to prevent
potential transmission to others in the clinic setting.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is appropriate for specimen handling but does not address the need for immediate infection control measures for the client and others in the clinic setting.
D. Moving the client to a private room, keeping the door closed, and initiating droplet precautions is the most important action to take to prevent potential transmission of COVID-19 to others in the clinic setting, given the client's symptoms and recent travel history.

A. Explain the purpose of a low bacteria diet. B. Use standard precautions and wear a mask. C. Send wound drainage for culture and sensitivity. D. Monitor the client's white blood cell count. E. Institute contact precautions for staff and visitors.

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

Explanation

A. Explaining the purpose of a low bacteria diet is not directly relevant to the management of osteomyelitis or MRSA infection. This intervention would not be included in the plan of care.
B. Using standard precautions and wearing a mask is essential when caring for a client with an open draining wound, especially when MRSA infection is suspected. This helps prevent the spread of infection to healthcare workers and other clients.
C. Sending wound drainage for culture and sensitivity is important to identify the causative organism and determine the most effective antibiotic therapy.
D. Monitoring the client's white blood cell count is important for assessing the client's response to treatment and detecting any signs of worsening infection.
E. Instituting contact precautions for staff and visitors is necessary to prevent the transmission of MRSA to others. This includes wearing gowns and gloves when entering the client's room and ensuring proper hand hygiene practices are followed.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

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Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply

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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?

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