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. Excessive sweating, a low sodium diet, and diarrhea can all lead to dehydration and electrolyte imbalances, particularly low sodium levels (hyponatremia). Lithium is primarily excreted by the kidneys, and its clearance is influenced by sodium levels in the body. Decreased sodium levels can impair lithium excretion, leading to increased lithium levels and potential toxicity.

A. Green tea contains caffeine, which is a diuretic and can increase urine output. Since lithium is excreted primarily by the kidneys, increased urine output can lead to decreased lithium levels in the body and potentially subtherapeutic levels.

B. While exercise can increase sweat production, leading to fluid and electrolyte loss, moderate exercise alone is unlikely to cause significant lithium toxicity.

D. Increasing sodium intake can potentially enhance lithium excretion by promoting its renal clearance not accumulation and toxicity.

A. flooding. B. systematic desensitization. C. cognitive restructuring. D. combination therapy.

Correct Answer is B

Explanation

B. Systematic desensitization is a behavioral therapy technique used to treat phobias, anxiety disorders, and other fear-related conditions. It involves exposing the individual to the feared stimulus or situation gradually, starting with less anxiety-provoking scenarios and progressing to more challenging ones, while simultaneously teaching relaxation techniques to reduce anxiety.

Systematic desensitization is considered a more gentle and controlled approach compared to flooding and is often preferred for individuals with specific phobias or moderate levels of anxiety.

A. Flooding is a behavioral therapy technique that involves exposing the individual to the feared stimulus or situation at full intensity, without any gradual buildup or relaxation techniques. However, flooding can be highly distressing and overwhelming for some individuals, and it may not be suitable for everyone, especially those with severe anxiety or trauma-related disorders.

C. Cognitive restructuring is a cognitive-behavioral therapy technique used to identify and challenge irrational or negative thoughts and beliefs that contribute to emotional distress or maladaptive behaviors. While cognitive restructuring may be incorporated into treatment for anxiety disorders, it focuses more on addressing cognitive distortions rather than directly exposing the individual to feared stimuli or teaching relaxation techniques.

D. Combination therapy refers to the use of multiple therapeutic approaches or techniques simultaneously or sequentially to address a client's psychological symptoms or concerns. While combination therapy may involve elements of systematic desensitization, cognitive restructuring, and other techniques, it does not represent a specific therapeutic approach or technique on its own.

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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 who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Correct Answer is C

Explanation

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called which of the following?

Correct Answer is B

Explanation

A nurse is caring for a client with paranoid personality disorder who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

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?

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)

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 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?

An anxiolytic agent has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective?