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":"C"}
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. "You will need an attorney to appoint a health care surrogate": It is not necessary to involve an attorney to designate a health care surrogate. Most states allow clients to complete the form themselves using standardized documents, making it accessible without legal assistance.
B. "You should appoint a family member as your health care surrogate": The surrogate does not have to be a family member; the client may choose any competent adult they trust to make health care decisions on their behalf. Emphasizing family only limits the client’s autonomy in selecting a trusted decision-maker.
C. "Once you have completed a living will it cannot be changed": Advanced directives, including living wills, can be updated or revoked at any time as long as the client has decision-making capacity. This flexibility allows clients to adjust their wishes as circumstances or preferences change.
D. "Your health care surrogate will make decisions on your behalf if you are unable": The primary role of a health care surrogate is to make medical decisions for the client when they lack the capacity to do so. This ensures that the client’s preferences and best interests are respected in situations where they cannot communicate their wishes.
Correct Answer is C
Explanation
A. Positive clonus: Clonus indicates neuromuscular irritability and is a sign of worsening preeclampsia rather than therapeutic control. The presence of clonus suggests inadequate suppression of central nervous system excitability.
B. Respiratory rate 10/min: A respiratory rate of 10 per minute indicates respiratory depression, which is a sign of magnesium toxicity. This finding reflects an adverse effect rather than a therapeutic response.
C. Deep tendon reflexes 2+: Normal deep tendon reflexes indicate that magnesium levels are within the therapeutic range. This finding reflects effective seizure prophylaxis without evidence of magnesium toxicity.
D. Urinary output 20 mL/hr: Low urine output suggests impaired renal clearance of magnesium, increasing the risk for toxicity. Adequate urine output is needed to safely eliminate magnesium, so this finding is concerning rather than therapeutic.
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