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 B

Explanation

B. This option promotes a calming and supportive environment that minimizes sensory stimuli and helps maintain orientation, reducing the risk of exacerbating symptoms of delirium and illusions.

A. Having the client sit by the nurse's desk may provide some supervision and reassurance, but keeping the television on can contribute to sensory overload and increase confusion, especially if the client is experiencing illusions.

C. Keeping the room shadowy with soft lighting and continuously playing a radio may create an environment that is disorienting and confusing for the client with delirium.

D. Maintaining bright lighting around the clock may disrupt the client's sleep-wake cycle and exacerbate symptoms of delirium. Interrupting the client's sleep by awakening hourly for mental status checks can also contribute to sleep deprivation and increase agitation and confusion

A. The client tells the nurse he is a government agent. B. The client tells the nurse that he is too tired to attend the group meeting. C. The client states. "I see purple bugs crawling on the wall." D. The client states, "My heart is pounding out of my chest."

Correct Answer is D

Explanation

D. This statement indicates symptoms of anxiety, which alprazolam is commonly prescribed to alleviate. Alprazolam is a benzodiazepine medication with anxiolytic properties, meaning it helps reduce feelings of anxiety and promote relaxation.

A. This statement suggests the presence of delusional thinking, which is a common symptom of schizophrenia. Alprazolam is not typically indicated for the treatment of delusions associated with schizophrenia.

B. While fatigue may be distressing for the client, it is not an indication for the use of alprazolam. Alprazolam is specifically prescribed for the management of anxiety symptoms.

C. This statement suggests the presence of hallucinations, which are another common symptom of schizophrenia. Alprazolam is not indicated for the treatment of hallucinations associated with schizophrenia.

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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

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

Correct Answer is D

Explanation

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

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A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

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?

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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?

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