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 C

Explanation

A. "If I decide to get implants in my arm, I will get them replaced every 10 years.": Contraceptive implants, such as etonogestrel (Nexplanon), typically last about 3 to 5 years, not 10 years. Misunderstanding the replacement timeline could leave a client unprotected against pregnancy if not corrected.

B. "If I decide to get pregnant again, tubal reconstruction is a reliable option.": Tubal ligation is considered a permanent form of contraception. Although tubal reversal surgery exists, it is not always successful and is not a reliable or guaranteed method for restoring fertility.

C. "I get the birth control injection, I will need an injection 4 times a year.": The birth control injection, such as depot medroxyprogesterone acetate (Depo-Provera), is administered every 3 months, which totals about 4 injections per year. This statement shows a correct understanding of the injection schedule.

D. "If I get an IUD placed, I will not have menstrual bleeding.": Some types of IUDs, particularly hormonal IUDs, may reduce menstrual bleeding significantly, but complete absence of bleeding does not occur in all clients. Copper IUDs, in contrast, may actually increase menstrual bleeding and cramping.

A. Place the client in a supine position B. Empty the collection chamber every 8 hr C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4hr

Correct Answer is C

Explanation

A. Place the client in a supine position: A supine position can impair lung expansion and increase the risk of respiratory complications. Clients with a chest tube are best positioned in a semi-Fowler’s or high-Fowler’s position to promote lung re-expansion and ease of breathing.

B. Empty the collection chamber every 8 hr: The collection chamber in a chest drainage system should not be emptied routinely, it should be emptied as needed to prevent it from overfilling. It is a closed system, and breaking it by emptying can introduce infection or disrupt the pressure needed for effective drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the chest drainage system below chest level uses gravity to promote drainage and prevents backflow of fluid or air into the pleural space. This positioning is essential to maintain the effectiveness and safety of the chest tube system.

D. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended as it can lead to a dangerous buildup of air (tension pneumothorax). Clamping is reserved for specific, short-term procedures under direct provider orders, such as changing the drainage system.

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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

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Correct Answer is C

Explanation

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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.