A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse 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?
"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?"
"What did the night nurse do that makes you think she is aloof?"
The Correct Answer is D
A) Incorrect- This response might address the client's concern but doesn't directly address her dichotomous thinking or provide immediate therapeutic communication.
B) Incorrect- While showing happiness for the client's improvement is positive, this response does not address the client's behavior or engage with her dichotomous tendency.
C) Incorrect- This response acknowledges the client's liking but doesn't address the dichotomous thinking pattern or provide an effective therapeutic response.
D) Correct- answering this question encourages the client to express her concerns and perceptions, fostering communication. This approach acknowledges the client's feelings and provides an opportunity for her to discuss the issue, potentially leading to a productive conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.
Correct Answer is ["A","D","E"]
Explanation
A) Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B) Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C) Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D) Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E) Correct- Educating the client about potential triggers supports better self-management.
F) Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G) Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H) Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.
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