A nurse is assisting with the care of a client.
The nurse is collecting data from the client.
Drag 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":"C","dropdown-group-2":"E"}
Rationale for correct choices:
• Emotional lability: The client demonstrates rapid and intense shifts in mood, such as being angry and hostile toward staff, then later praising the nurse excessively. This instability in affect is characteristic of borderline personality disorder (BPD). Emotional lability often leads to interpersonal conflicts and impulsive behaviors, which were observed in aggressive interactions with peers. Recognizing these shifts is essential for guiding therapeutic interventions.
• Fear of abandonment: Clients with BPD frequently experience intense fear of real or perceived abandonment, influencing their relationships and behaviors. The client’s alternating hostility and praise toward the nurse may reflect anxiety over potential rejection or inconsistent attachment. Identifying this fear helps the nurse implement consistent, supportive care while maintaining professional boundaries.
Rationale for incorrect choices:
• Elevated body temperature: There is no evidence of fever or infection in the client. Elevated temperature is not a feature of BPD. It reflects physiological issues unrelated to emotional or behavioral manifestations.
• Tactile hallucinations: The client has not reported or demonstrated perceptual disturbances such as hallucinations. Psychotic symptoms are not part of the core diagnostic features of BPD. Monitoring for hallucinations is unnecessary unless indicated by comorbid conditions.
• Increased heart rate: While heart rate may increase transiently during stress or agitation, it is a physiological response and not a defining characteristic of BPD. Emotional lability and interpersonal fears more accurately reflect the disorder’s manifestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. A nurse discovers that a client's family member has administered a PCA dose: Unauthorized administration of medication by a family member constitutes a medication error and breach of safety protocols, requiring an incident report to document the event and prevent future occurrences.
B. A nurse observes a client vomiting after receiving an oral pain medication: Vomiting can be an expected side effect of medications. While it should be documented in the medical record, it does not typically require an incident report unless it results in harm or deviates from standard care.
C. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client: Over-infusion of fluids is a serious medication/therapy error with potential for harm. An incident report is necessary to document the error, ensure client safety, and support system improvements.
D. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: Proper restraint removal is part of standard care and does not constitute an incident.
Correct Answer is C
Explanation
A. Collect a sputum sample: Attempting to collect a sputum sample can trigger a gag or cough reflex, potentially causing complete airway obstruction in a child with epiglottitis. This action is unsafe in a suspected airway emergency.
B. Obtain a specimen for throat culture: Throat culture requires direct visualization or manipulation of the throat, which can provoke laryngospasm or airway compromise in epiglottitis. Invasive procedures should be avoided until the airway is secured.
C. Determine the preschooler's oxygen saturation level: Assessing oxygen saturation is a noninvasive way to monitor respiratory status and detect hypoxia early. It provides critical information on the child’s oxygenation without manipulating the airway, making it a safe first action.
D. Inspect the preschooler's tonsils for edema: Direct inspection of the throat can precipitate sudden airway obstruction in epiglottitis. Visual examination should be avoided until the child is in a controlled setting with airway management available.
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