A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select 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":"D"}

emotional lability: The client’s sudden and intense shifts in mood, such as calling the nurse "horrible" and then later saying the nurse is "the best," are classic signs of emotional lability. This rapid mood instability is a hallmark feature of borderline personality disorder and reflects difficulties regulating emotions.
increased heart rate: An increased heart rate is a physiological response often linked to anxiety, panic, or substance use but is not a defining characteristic of borderline personality disorder. It does not directly represent a core emotional or relational disturbance seen in this disorder.
elevated body temperature: Elevated body temperature is a physical finding associated with infection, inflammation, or drug reactions. It is not a behavioral or psychological symptom related to borderline personality disorder.
tactile hallucinations: Tactile hallucinations, such as feeling sensations that are not there, are associated with psychotic disorders or substance intoxication rather than borderline personality disorder. They are not characteristic features of this condition.
fear of abandonment: Individuals with borderline personality disorder have a profound fear of abandonment, whether real or perceived. This fear often leads to intense emotional reactions and unstable interpersonal relationships, as seen in the client’s extreme reactions toward the nurse.

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Correct Answer is A

Explanation

A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.

B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.

C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.

D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.

A. Clamp the urinary catheter tubing. B. Replace the indwelling urinary catheter with a smaller diameter catheter C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation D. Allow the tubing to hang below the drainage bag

Correct Answer is C

Explanation

A. Clamp the urinary catheter tubing: Clamping the catheter tubing is not appropriate because it can lead to bladder distention, increased pressure, and risk of bladder rupture. Maintaining continuous drainage is essential to prevent complications following prostate surgery.

B. Replace the indwelling urinary catheter with a smaller diameter catheter: Replacing the catheter is not the first intervention when clots and dark red blood are present. Smaller diameter catheters would actually be less effective in clearing clots and could worsen the blockage.

C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation: Manual irrigation helps to clear clots that may be obstructing the catheter, promoting continued drainage and reducing the risk of bladder distention. Gentle irrigation is the appropriate first step to manage clot formation.

D. Allow the tubing to hang below the drainage bag: The drainage tubing should always be positioned above the collection bag to maintain gravitational drainage. Letting the tubing hang below the bag would impair drainage and could lead to backflow and infection.

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A nurse is assisting with the care of a client. The nurse is collecting data from the client. Select 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (APIT

Correct Answer is A

Explanation

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notes clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select 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.