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 D
Explanation
A. Visual Analog Scale: The visual analog scale requires the child to understand and mark a point on a line representing pain intensity. This scale is appropriate for older children, usually around 7 years and older, and not for an 8-month-old infant.
B. FACES pain scale: The FACES scale uses facial expressions to help children identify pain intensity, but it is suitable for children aged 3 years and older who can understand the concept of choosing a face to represent their pain.
C. Oucher scale: The Oucher scale also relies on the child’s ability to self-report pain by selecting a photograph or numerical representation. It is not appropriate for infants who cannot communicate their pain cognitively.
D. FLACC scale: The FLACC scale assesses pain in infants and young children by observing five criteria: Face, Legs, Activity, Cry, and Consolability. It allows the nurse to evaluate pain objectively in an 8-month-old who cannot verbally self-report.
Correct Answer is A
Explanation
A. “I’d like to hear your thoughts about giving yourself this medication.”: This response uses open-ended, therapeutic communication that invites the client to express concerns, fears, or misconceptions. It demonstrates respect for autonomy and helps build trust while allowing the nurse to assess readiness to learn. Understanding the client’s perspective is essential before providing education or problem-solving.
B. “You will suffer serious health issues if you don't take your medication.”: This response uses fear and threats, which can increase anxiety and resistance rather than promote cooperation. It does not encourage dialogue or address the client’s underlying concerns.
C. “Why don't you want to learn how to give yourself your medication?”: Questions beginning with “why” can feel accusatory or judgmental, causing the client to become defensive. Although the nurse needs to understand the client’s reluctance, this phrasing may inhibit open communication. A more neutral approach is preferred.
D. “Have you considered how your decision to refuse medication will affect your family?”: This response applies guilt and shifts the focus away from the client’s feelings and autonomy. It does not promote therapeutic communication or support informed decision-making. Using guilt can undermine trust and collaboration.
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