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 ["B","C","D","F"]
Explanation
Choice A Reason: Selecting only food items with no fat is not recommended because some fats, particularly unsaturated fats, are beneficial for health and should be included in a balanced diet.
Choice B Reason: Taking a cinnamon supplement may be beneficial as some studies suggest that cinnamon can help lower blood sugar levels and improve insulin sensitivity.
Choice C Reason: Minimizing the number of refined grains in the diet is advised because refined grains can have a negative impact on blood sugar control and may increase the risk of type 2 diabetes.
Choice D Reason: Eliminating sugary beverages and juices from the diet is beneficial as these can lead to spikes in blood sugar levels and contribute to weight gain, which is a risk factor for type 2 diabetes.
Choice E Reason: Doubling the usual amount of protein in the diet is not necessary and could lead to an excessive intake of calories. Protein should be consumed in moderation and as part of a balanced diet.
Choice F Reason: Increasing the amount of dietary fiber is recommended because fiber can help manage blood sugar levels and reduce the risk of developing type 2 diabetes.
Correct Answer is A
Explanation
Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.
Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.
Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.
Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
