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

Answer and Explanation

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.

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Free Nursing Study Resources

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

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

Correct Answer is ["2.4"]

Explanation

Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:

175 lbs ÷ 2.2 = 79.55 kg

Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:

3 units/kg × 79.55 kg = 238.65 units

Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:

238.65 units ÷ 100 units/mL = 2.39 mL

So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).

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Naxlex Comprehensive Predictor Exams

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

The healthcare provider has prescribed heparin, 3 units/kg to be administered via IV push for a client who weighs 175 pounds. The vial is labeled as "100 units/mL." How many mL should the nurse administer? (Please enter the numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.4"]

Explanation

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