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A nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data from the client.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

and indicate manifestations of borderline personality disorder.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

  • Emotional lability refers to rapid and intense mood swings, which are a common characteristic of borderline personality disorder. Individuals with this disorder may experience extreme shifts in emotions, such as sudden anger, sadness, or elation, often triggered by minor events.
  • Fear of abandonment is another core feature of borderline personality disorder. Individuals may go to great lengths to avoid real or perceived rejection, leading to unstable relationships and intense emotional reactions. This fear can manifest as extreme clinginess, hostility, or impulsivity when they believe they are being neglected or left alone.
  • Increased heart rate and elevated body temperature are physiological responses that can occur in various medical conditions but are not specific to borderline personality disorder. Tactile hallucinations, which involve the sensation of touch without a physical stimulus, are more commonly associated with substance use disorders or psychotic disorders rather than borderline personality disorder.


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Related Questions

Correct Answer is B

Explanation

A. Place the client in a room with a high-efficiency particulate air (HEPA) filter. HEPA filtration is used for airborne precautions, such as tuberculosis. MRSA is transmitted through direct contact, so a private room or cohorting with another MRSA-positive client is sufficient.
B. Don gloves prior to assisting the client with brushing their teeth. MRSA is primarily spread via direct contact with infected wounds, secretions, or contaminated surfaces. Wearing gloves when providing personal care helps prevent transmission.
C. Ensure that the negative air pressure is active for the client's room. Negative pressure rooms are necessary for airborne pathogens like tuberculosis or measles. MRSA does not require airborne precautions, so this is not needed.
D. Have the client wear a mask when they are out of their room. A mask is only required if MRSA is present in the respiratory tract and the client has a productive cough. Standard contact precautions, such as hand hygiene and personal protective equipment, are the primary infection control measures.

Correct Answer is D

Explanation

A. Kleihauer-Betke test. This test is used to detect fetal-maternal hemorrhage by identifying fetal red blood cells in maternal circulation. It is not related to a nonreactive NST, which indicates the need for further fetal well-being assessment rather than checking for fetal-maternal bleeding.
B. Amnioinfusion. This procedure involves infusing fluid into the amniotic sac to relieve umbilical cord compression or dilute meconium-stained amniotic fluid. It is not an appropriate intervention for a nonreactive NST, as it does not assess fetal oxygenation or reactivity.
C. Administration of terbutaline. Terbutaline is a tocolytic used to relax the uterus and prevent preterm labor. It is not indicated for a nonreactive NST, as the concern in this scenario is fetal well-being rather than uterine activity.
D. Contraction stress test. A nonreactive NST means that the fetal heart rate does not demonstrate adequate accelerations, which can indicate potential fetal hypoxia. A contraction stress test is performed next to evaluate how the fetal heart rate responds to contractions, helping determine if the fetus can tolerate labor.

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