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
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Correct Answer is D
Explanation
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
Correct Answer is D
Explanation
Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.
Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.
Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.
Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.
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