A client who has 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?

"What did the night nurse do that makes you think the nurse is aloof?"

"Tomorrow I will talk to that nurse about how you were treated last night."

"I am happy that you are getting better and will be able to go home."

"I am glad you like me. Which nurse was acting aloof to you?"

Answer and Explanation

The Correct Answer is C

Choice A reason: Asking for specifics about the night nurse's behavior could reinforce negative perceptions and does not address the client's current emotional state.

Choice B reason: Promising to talk to the night nurse may validate the client's split perception without verifying the facts.

Choice C reason: Expressing happiness for the client's improvement and discharge focuses on positive aspects and avoids engaging in potentially manipulative behavior.

Choice D reason: Acknowledging a preference for certain nurses can reinforce the client's splitting behavior, which is unhelpful in managing borderline personality disorder.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While nutrition is important, a high-protein diet is not specific to the management of heart failure.

Choice B reason: Weighing every morning allows for monitoring of fluid retention, which is a key aspect of managing heart failure.

Choice C reason: Range of motion exercises are good for overall health but are not specific to heart failure management.

Choice D reason: Limiting fluid intake is important, but it is more critical to monitor weight daily to detect fluid retention early.

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

Correct Answer is C

Explanation

Choice A reason: Cooling the bottle is not necessary and shaking it is only required if the instructions specify to do so to mix the medication.

Choice B reason: Inserting the tip of the dropper into the ear canal is not recommended as it can introduce bacteria and cause injury.

Choice C reason: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.

Choice D reason: Administering the drops with the head held upright is not the correct method; the head should be tilted to allow the drops to flow down into the ear canal.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

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 C

Explanation

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

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?

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

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)?