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 D

Explanation

A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.

B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.

C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.

D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.

A. Dry skin B. Hypotension C. Constipation D. Urinary retention

Correct Answer is B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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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 client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

Correct Answer is D

Explanation

A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

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.