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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Advance directives are the same as a consent form for health care treatment": Advance directives are different from a consent form. A consent form is specific to the current treatment or procedure, while advance directives outline future healthcare wishes in the event the client becomes unable to make decisions.
B. "Advance directives are for clients who have life-threatening conditions.": While advance directives are especially important for clients with serious illnesses, they are appropriate for all adults, regardless of current health status, to ensure their wishes are known and respected if they become incapacitated.
C. "Advance directives must be approved by your lawyer.": Advance directives do not require a lawyer's approval to be valid. They usually need to be signed by the client and witnessed or notarized, depending on state laws, but legal counsel is not mandatory for completing one.
D. "Advance directives protect your right to make your own health care decisions.": Advance directives ensure that a client’s wishes regarding healthcare are known and respected even if they cannot voice them later. They preserve the client’s autonomy and legal rights concerning treatment preferences.
Correct Answer is D
Explanation
A. The client recently received a pay raise at work: Receiving a pay raise is generally considered a positive life event that can improve self-esteem and financial security. Positive achievements like this are not associated with increased suicide risk and may actually serve as protective factors against depressive symptoms.
B. The client is married and has children: Being married and having children are typically viewed as protective factors against suicide. Strong familial bonds and social connections provide emotional support, a sense of responsibility, and a buffer against feelings of isolation or hopelessness that often contribute to suicidal ideation.
C. The client has a strong religious affiliation: Strong religious beliefs can serve as a significant protective factor against suicide by providing hope, purpose, community support, and moral objections to self-harm. Clients with strong spiritual ties often demonstrate greater resilience during periods of emotional distress.
D. The client has a history of chronic back pain: Chronic pain is a known risk factor for suicide because it can lead to feelings of hopelessness, helplessness, and a diminished quality of life. Clients with long-term physical pain often experience comorbid depression and are at higher risk for suicidal thoughts and behaviors.
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