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?"
None
None
The Correct Answer is A
Choice A reason: This response invites the client to describe specific behaviors, promoting reality testing and reducing global judgments. It shifts the focus to observable facts, encourages problem solving, and sets a neutral, nonjudgmental tone that helps manage splitting without taking sides or reinforcing dichotomous thinking.
Choice B reason: Promising to speak to the other nurse takes the nurse’s role beyond immediate assessment and may reinforce the client’s splitting by implying advocacy against staff. It avoids eliciting specifics, delays direct exploration of the client’s perception, and can undermine professional boundaries and accountability.
Choice C reason: Offering general reassurance about discharge does not address the client’s immediate interpersonal splitting or the complaint about the night nurse. It sidesteps the behavior, misses an opportunity for clarification, and fails to help the client examine or verbalize the concrete reasons behind their polarized view.
Choice D reason: Responding with flattery while asking which nurse was aloof can validate the client’s splitting and encourage manipulation or favoritism. It risks reinforcing the “favorite” dynamic and does not promote objective description of events or help the client process feelings in a therapeutic, boundary‑maintaining way.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
Choice A reason: Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening.
Choice B reason: There is no need to restrict the child to clear liquids for several days unless specifically instructed by the physician for a particular reason. After cardiac catheterization, patients are usually encouraged to resume their normal diet as tolerated to promote recovery unless there are other concerns that warrant dietary restrictions1.
Choice C reason: Avoiding baths or showers is generally recommended immediately after cardiac catheterization to prevent infection at the catheter insertion site. However, this restriction is usually only for a few days, not indefinitely. The site needs to be kept dry and clean until it has sufficiently healed.
Choice D reason: Keeping a pressure dressing on the site for one week is not typically necessary. The dressing is usually checked and changed by healthcare professionals, and the site is monitored for healing. The dressing may be removed after a certain period, often before one week, as long as there are no signs of bleeding or infection.
Choice E reason: Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection.
Choice F reason: The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it’s important to use the correct dosage and to ensure it doesn’t interfere with any other medications the child may be taking.
Correct Answer is B
Explanation
Choice A reason: Reducing the risk for infection is important but not the primary goal for DJD as it is not primarily an infectious condition.
Choice B reason: Achieving satisfactory pain control is the primary goal in the management of DJD to improve the client's quality of life and functional ability.
Choice C reason: Obtaining adequate rest and sleep is beneficial for overall health but is secondary to pain control in the management of DJD.
Choice D reason: Improving stress management skills can help with overall well-being but is not the primary focus of care for a client with DJD.
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