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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.
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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Related Questions

Correct Answer is ["A","B","D","E","F","G"]

Explanation

  • Administer betamethasone: Betamethasone is administered to pregnant clients at risk of preterm delivery to promote fetal lung maturity. Given the client's gestational age of 31 weeks and signs of severe preeclampsia, administering corticosteroids is critical to prepare for potential early delivery.
  • Monitor intake and output every hour: Severe preeclampsia can impair renal function, leading to decreased urine output and worsening fluid retention. Hourly monitoring of intake and output helps detect early signs of renal compromise and fluid overload, both of which require immediate intervention.
  • Assist RN with performing a vaginal examination every 12 hr: Vaginal examinations are avoided in cases of severe preeclampsia unless absolutely necessary because they can stimulate uterine contractions or introduce infection. Therefore, routinely assisting every 12 hours with vaginal exams is not appropriate in this client's plan of care.
  • Obtain a 24-hr urine specimen: A 24-hour urine collection assesses the degree of proteinuria and provides a clearer diagnostic picture of the severity of preeclampsia. Quantifying protein excretion helps guide clinical management and decisions about timing of delivery.
  • Provide a low-stimulation environment: A calm, quiet environment minimizes the risk of seizure activity in clients with severe preeclampsia. Reducing auditory, visual, and environmental stimulation is a standard preventative measure to decrease neurological irritability.
  • Give antihypertensive medication: Severe hypertension must be promptly treated to prevent complications like stroke, placental abruption, and progression to eclampsia. Administering antihypertensive therapy helps stabilize maternal blood pressure and protects both maternal and fetal health.
  • Maintain bedrest: Bedrest helps reduce blood pressure and physical stress, promoting better perfusion to the placenta. Although strict bedrest is controversial long-term, short-term bedrest is often used in severe preeclampsia management while stabilization measures are implemented.

Correct Answer is []

Explanation

  • Prepare the client for an emergency cesarean birth: Emergency cesarean delivery is indicated in cases of fetal distress or placenta previa with severe bleeding at term. In a hydatidiform mole, there is no viable fetus, and the priority is evacuation of the molar tissue rather than delivery by cesarean section.
  • Prepare the client for suction curettage: Suction curettage is the treatment of choice for a hydatidiform mole. It allows for the complete evacuation of abnormal trophoblastic tissue, preventing complications such as severe hemorrhage and progression to malignant gestational trophoblastic disease.
  • Anticipate a prescription for methotrexate: Methotrexate is primarily used to treat ectopic pregnancies or persistent gestational trophoblastic disease after a molar pregnancy, not for initial management. Immediate evacuation of the mole by suction curettage is the first-line intervention for this client.
  • Remind the client that weekly blood tests are needed to measure pregnancy hormone: Following a molar pregnancy, weekly beta-hCG tests are critical to monitor for residual trophoblastic tissue or the development of choriocarcinoma. A declining beta-hCG confirms the resolution of disease, while a plateau or rise indicates persistent disease.
  • Administer terbutaline: Terbutaline is a tocolytic medication used to relax the uterus in cases of preterm labor. In the case of a hydatidiform mole, uterine evacuation is necessary rather than uterine relaxation, making terbutaline inappropriate for this situation.
  • Vaginal bleeding: Clients with a hydatidiform mole are at risk for significant vaginal bleeding due to the abnormal growth of trophoblastic tissue. Monitoring the amount and type of vaginal bleeding helps detect hemorrhage or retained molar tissue requiring urgent intervention.
  • Blood pressure: Elevated blood pressure is a potential complication of hydatidiform mole, similar to preeclampsia, and can occur even in the first or second trimester. Regular monitoring of blood pressure is essential to detect worsening hypertensive symptoms early.
  • Uterus for hypertonicity: Hypertonicity of the uterus is typically monitored in cases of labor or uterine rupture concerns. In a hydatidiform mole, the uterus is distended by abnormal tissue but hypertonicity is not a primary concern needing monitoring in this condition.
  • Unilateral pelvic pain: Unilateral pelvic pain is more characteristic of ectopic pregnancy rather than a molar pregnancy. In hydatidiform mole, generalized uterine enlargement and discomfort are more typical, so unilateral pelvic pain is not a focus for this client.
  • Cervical dilation per provider: Cervical dilation is not the main indicator of progress or concern with a molar pregnancy. The focus is on removing molar tissue and monitoring beta-hCG levels, not on the progress of cervical changes like in labor.

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