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 ["A","B","E"]

Explanation

Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.

Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.

Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.

Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.

A. Walk frequently during recovery. B. Advance diet from clear liquids to full liquid. C. Anticipate weight loss will continue even with normal diet. D. Begin taking supplements per the healthcare provider's orders. E. Expect immediate return of ovulation. F. Start with room temperature water. G. Encourage three large meals a day.

Correct Answer is ["A","B","D","F"]

Explanation

Choice A reason: Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery.
Choice B reason: After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site.
Choice D reason: Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition.
Choice F reason: Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.
Choice C reason: While weight loss is expected after bariatric surgery, it is not accurate to anticipate that weight loss will continue with a normal diet. Patients must adhere to a specific postoperative diet and lifestyle changes to ensure continued weight loss and avoid weight regain.
Choice E reason: Ovulation and fertility can be affected by significant weight loss; however, it is not appropriate to expect an immediate return of ovulation post-surgery. Fertility changes can vary from person to person and may take time.
Choice G reason: Encouraging three large meals a day is contrary to the recommended dietary guidelines post-bariatric surgery. Patients are advised to eat small, frequent meals to accommodate the reduced stomach capacity and to prevent symptoms of dumping syndrome.
Choice H reason: Dietician appointments are not optional but are a critical component of postoperative care. Regular follow-up with a dietician ensures that patients receive personalized nutritional guidance and support as they adjust to their new dietary habits.

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Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

Patient Data Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

A client has received a prescription for loratadine suspension, 10 mg to be taken orally once a day. The bottle is labeled as "Loratadine for Oral Suspension, USP 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Please enter the numerical value only.)

A nurse is caring for a client who reports having run out of aspirin a week ago and has been taking ibuprofen as a substitute. Which information should the nurse obtain from the client first?

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

A parent asks the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

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