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. 32 lb: A weight gain of 32 lb exceeds the recommended range for a client with a prepregnancy BMI ≥30 (obese). Excessive weight gain increases the risk of gestational diabetes, hypertension, and complications during delivery. Staying within guideline ranges supports maternal and fetal health.
B. 8 lb: A gain of 8 lb is below the recommended range and may indicate inadequate nutrition, which can compromise fetal growth and development. Clients with obesity are advised to gain more than this to support a healthy pregnancy while avoiding excessive weight.
C. 24 lb: A gain of 24 lb slightly exceeds the recommended range for obese clients. While less risky than very high gains, it may still increase the likelihood of postpartum weight retention and obstetric complications.
D. 16 lb: For a prepregnancy BMI ≥30, the recommended total weight gain is 11–20 lb. A gain of 16 lb falls within this guideline, balancing the needs of fetal growth while minimizing maternal and fetal complications. This makes it the most appropriate target for dietary teaching.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
• a change in mood: Isotretinoin has been associated with psychiatric effects including depression, mood swings, aggression, and suicidal ideation, particularly in adolescents. Any noticeable mood or behavioral changes require immediate provider notification so the medication can be reassessed and mental health support initiated if needed.
• decreased night vision: Isotretinoin can impair dark adaptation and cause decreased night vision due to its effects on the retina. This adverse effect may be sudden or irreversible, making early reporting essential to prevent safety risks such as accidents while driving in low-light conditions.
Rationale for incorrect choices:
• nausea: Mild gastrointestinal upset can occur with isotretinoin and is generally expected rather than emergent. This symptom is usually managed with supportive measures and does not require immediate discontinuation unless severe or persistent.
• dry mouth: Mucocutaneous dryness, including dry lips and mouth, is a very common and expected side effect of isotretinoin. This is typically managed with hydration and emollients and does not warrant urgent provider notification.
• the development of dry eyes: Dry eyes are a common isotretinoin effect related to decreased sebaceous gland activity. While uncomfortable and relevant to report at routine follow-up, it is not an urgent finding unless severe or affecting vision.
• sunburn: Photosensitivity can occur during isotretinoin therapy, making sunburn more likely. This is addressed with sun protection education and does not indicate a serious adverse reaction requiring immediate notification.
• engagement in sexual activity: Sexual activity itself is not an adverse effect of isotretinoin. Although pregnancy prevention is critical due to teratogenicity, sexual activity alone does not represent a medication-related complication.
• worsening of acne: Acne may initially worsen during early isotretinoin therapy as part of the treatment response. This is a known and expected effect and does not require urgent provider contact unless severe or accompanied by systemic symptoms.
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