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 C
Explanation
A. “I will decrease my fluid intake to reduce incontinence.”: Reducing fluid intake can lead to concentrated urine and bladder irritation, which may worsen urinary urgency and incontinence. Adequate hydration is encouraged rather than fluid restriction for managing cystocele symptoms.
B. “I will experience less urinary incontinence if I use artificial sweeteners.”: Artificial sweeteners can irritate the bladder and increase urinary frequency or urgency. Their use may exacerbate urinary incontinence rather than improve symptoms.
C. “I will practice perineal exercises to decrease urinary leakage.”: Perineal (Kegel) exercises strengthen the pelvic floor muscles that support the bladder and urethra. Regular practice can improve muscle tone and reduce urinary leakage associated with a cystocele.
D. “I should use a perineal spray to reduce odor from urinary leakage.”: Perineal sprays may mask odor but do not address the underlying pelvic floor weakness. Some products can also irritate the perineal area, potentially worsening discomfort or skin breakdown.
Correct Answer is C
Explanation
A. Place the client on bedrest: While limiting activity can prevent further strain, simply placing the client on bedrest does not immediately address airway compromise or improve oxygenation. Immediate interventions to relieve dyspnea take priority.
B. Obtain the client's ABG levels: Arterial blood gases provide valuable information about oxygenation and acid-base status, but drawing labs does not relieve acute respiratory distress. Assessment and interventions that improve breathing should come first.
C. Elevate the head of the client's bed: Elevating the head of the bed improves lung expansion, promotes oxygenation, and reduces the work of breathing. This is a primary, noninvasive intervention that directly addresses the client’s acute symptoms and should be implemented immediately.
D. Prepare the client for a ventilation perfusion scan: A V/Q scan helps diagnose pulmonary embolism but is a diagnostic measure. Diagnostic preparation does not take priority over interventions that relieve acute hypoxia and respiratory distress.
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