A nurse in an outpatient mental health center is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with paranoid personality disorder or borderline personality disorder. Each finding may support more than 1 personality disorder or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Relationship status

Concerns about Coworkers

Client statement

Skin alterations

Behavior pattern

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Rationale:

Relationship status: BPD is marked by instability in relationships, often due to intense fear of abandonment or difficulty managing emotional attachments. Sudden breakups or conflict with close partners are common, especially during emotional crises.
Concerns about coworkers: Individuals with PPD often misinterpret benign actions of others as malicious or threatening. Persistent beliefs that others are conspiring against them—despite little or no evidence—are core features of the disorder.
Client statement: Impulsivity is a diagnostic criterion for BPD. Risky behaviors like sudden, financially irresponsible purchases are driven by difficulty regulating emotion and can reflect an effort to escape negative feelings.
Skin alterations: Recurrent self-harm (e.g., superficial cutting) is a hallmark of BPD, typically used to cope with overwhelming emotional distress, feelings of emptiness, or perceived rejection or abandonment.
Behavior pattern: Blunted affect and lack of improvement may reflect emotional withdrawal seen in both BPD and PPD. In BPD, emotional dysregulation underlies these symptoms; in PPD, chronic mistrust can lead to guarded, affectively flat behavior and resistance to help.

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Correct Answer is B

Explanation

Rationale:

A. Bradycardia: Bradycardia is not a typical adverse effect of IV fluid therapy. If anything, fluid overload might contribute to hypertension or reflex tachycardia rather than a slowing of the heart rate.

B. Distended neck veins: Distended neck veins are a common sign of fluid volume overload, a potential adverse effect of IV therapy. This occurs when excess fluid increases venous pressure and can indicate worsening heart function or pulmonary congestion.

C. Weight loss: IV fluid therapy is expected to increase or stabilize weight due to fluid retention, not cause weight loss. Weight loss might instead indicate dehydration or catabolic states, not an adverse reaction to fluid infusion.

D. Bradypnea: Bradypnea is not typically caused by IV fluid therapy. In fluid overload, the more common respiratory symptom is tachypnea or dyspnea due to pulmonary congestion, not a slowed respiratory rate.

A. A client who requests assistance to use the bedside commode B. A client who requests to sit in the bedside chair while watching TV. C. A client who has a prescription for compression stockings and did not receive them. D. A client who consumes all the food from their meal tray

Correct Answer is C

Explanation

Rationale:

A. A client who requests assistance to use the bedside commode: This is a routine activity that falls within the scope of practice for assistive personnel. As long as the AP follows standard safety procedures, there is no immediate need to report this to the nurse.

B. A client who requests to sit in the bedside chair while watching TV: Allowing a client to sit up in a chair is within the AP’s role, provided the client is stable and fall precautions are followed. It does not require nurse notification unless there are complications.

C. A client who has a prescription for compression stockings and did not receive them: This indicates a potential lapse in prescribed therapy, which could increase the risk of complications like deep vein thrombosis. The nurse must be informed to evaluate and correct the omission promptly.

D. A client who consumes all the food from their meal tray: Reporting full meal consumption is not necessary unless the client is on a monitored diet or has specific nutritional concerns. In most cases, this is expected and requires only standard documentation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

Correct Answer is B

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer is C

Explanation

A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following Interventions should the nurse include in the plan of care?

Exhibits For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?