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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.
Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.
Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.
Correct Answer is B
Explanation
Choice A reason: Telling the charge nurse and refusing to administer the placebo could be seen as insubordination and does not address the ethical concerns associated with placebo use.
Choice B reason: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.
Choice C reason: Administering the placebo as prescribed without addressing the ethical implications could compromise the nurse's professional integrity and the patient's trust.
Choice D reason: Informing the client that a placebo was prescribed could undermine the treatment plan and the provider-patient relationship, potentially causing harm to the client.

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