A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

"I'm glad you feel comfortable with me."

"I am sorry I cannot be your friend."

"You feel other's don't understand you?"

"I'm here to help you just as all the staff members are."

Answer and Explanation

The Correct Answer is D

D. It acknowledges the client’s comfort while emphasizing the nurse’s professional role. It sets clear boundaries and reinforces that the nurse’s primary purpose is to provide care and support within the therapeutic context.

A. This response acknowledges the client’s feelings but does not set clear boundaries. It may

inadvertently encourage the client to view the nurse as a friend rather than a professional caregiver.

B. While this response establishes boundaries, it may come across as abrupt or cold. It lacks empathy and understanding.

C. This response reflects empathy and encourages further exploration of the client’s feelings. However, it does not address the professional boundaries explicitly.

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Correct Answer is C

Explanation

C. The child telling sexually explicit stories to peers could be concerning and warrants further investigation. A child speaking in this manner could indicate that they are frequently expose to sexual content of abuse
A. The child has a preference for associating with peers, rather than adults. While this may need further assessment, it does not necessarily point to sexual abuse.
B. Learning problems and shyness alone are not specific indicators of sexual abuse.

D. While poor hygiene and clothing conditions can be signs of neglect, they are not directly related to sexual abuse. Poor hygiene and clothing is more likely to point to child neglect.

A. Involuntary pelvic rocking and hip thrusting movements B. Facial grimacing and eye blinking C. Tongue thrusting and lip smacking D. Fine hand tremors and pill rolling E. Urinary retention and constipation

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

Explanation

A. Tardive dyskinesia can involve abnormal, involuntary movements of the hips, pelvis, and trunk.
B. Facial grimacing and eye blinking are common manifestations of tardive dyskinesia. These movements involve involuntary contractions of facial muscles, leading to facial distortions and repetitive blinking.
C. Tongue thrusting and lip smacking are classic signs of tardive dyskinesia. These movements involve involuntary protrusion of the tongue and repetitive puckering or smacking of the lips.

D. Fine hand tremors and pill rolling movements are more commonly associated with other movement disorders, such as Parkinsonism, which can also be caused by certain antipsychotic medications but are distinct from tardive dyskinesia.
E. Urinary retention and constipation are not typical symptoms of tardive dyskinesia. These symptoms may occur due to other factors, such as anticholinergic effects of medications or medical conditions unrelated to tardive dyskinesia.

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A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply)

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

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting. and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A client is seeking treatment for a specific phobia. The nurse in the anxiety disorders clinic documents that the client's anxiety is related to exposure to the phobic object. Which is a realistic outcome for anxiety self-control in this situation?

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?