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 C
Explanation
The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.
The other options are not correct because:
A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.
B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.
D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or effective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.
Correct Answer is B
Explanation
A. Elevated energy level: While cocaine use can initially cause increased energy, this is a temporary effect. The most consistent and concerning behavioral manifestation is drug-seeking behavior due to intense cravings.
B. Powerful craving for more: Cocaine is highly addictive and stimulates the brain's reward system, leading to a powerful and often uncontrollable craving for more of the drug, which is a hallmark of cocaine dependence.
C. High self-esteem: Cocaine use may cause temporary grandiosity, but it does not result in true or stable high self-esteem. Users often experience mood swings and depressive symptoms after the drug wears off.
D. Euphoria: Cocaine does cause euphoria, but it is short-lived. The craving for more, even after the initial high, is more defining and persistent in clients who test positive and are in the cycle of use.
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