A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?
"I don't like it when you address me with that tone of voice."
"I know you can, but are you going to read it or not?"
"Fine. Here is the schedule, and I will expect you to be on time to your therapies."
"We do this every day. Why are you so angry with me this morning?"
The Correct Answer is A
A)"I don't like it when you address me with that tone of voice.": This is the most therapeutic response. It addresses the inappropriate behavior (the rude tone) in a calm and direct manner, setting a clear boundary while remaining respectful. By focusing on the behavior, the nurse can maintain professionalism and avoid escalating the situation. This response also encourages the client to recognize the impact of their behavior without feeling attacked.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding the client is not a therapeutic approach and may worsen the client's feelings of guilt or shame. It's essential to approach clients with eating disorders with empathy and understanding rather than criticism.
B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: Encouraging the client to communicate with a nurse when she feels the urge to exercise is a supportive intervention. This allows the nurse to provide assistance, encouragement, or distraction techniques to help the client cope with the urge in a healthier way.
C. Praise the client for looking at herself in a mirror: Praising the client for looking at herself in a mirror may inadvertently reinforce body image concerns or obsessive behaviors related to appearance. Instead of focusing on the client's appearance, it's important to encourage behaviors and thoughts that promote self-acceptance and body positivity.
D. Restrict the client from being weighed: Restricting the client from being weighed may exacerbate anxiety and control issues related to weight. It's essential to monitor the client's weight as part of their overall health assessment and treatment plan. However, discussions about weight should be conducted sensitively and in collaboration with the client, focusing on health rather than numbers.
Correct Answer is C
Explanation
A. Bizarre behavior: Bizarre behavior is typically considered a positive symptom of schizophrenia rather than a negative symptom. Positive symptoms involve the presence of abnormal behaviors or experiences that are not typically seen in healthy individuals. Bizarre behavior can include hallucinations, delusions, disorganized thinking, and grossly disorganized or catatonic behavior.
B. Somatic delusions: Somatic delusions, where the individual believes they have a medical condition or physical defect that is not present, are also considered positive symptoms of schizophrenia. Positive symptoms involve distortions or exaggerations of normal functions.
C. Affective flattening: This is the correct choice. Affective flattening, also known as blunted affect, refers to a reduction in the intensity, range, and expression of emotional responses. Individuals with schizophrenia who exhibit affective flattening may have a limited range of facial expressions, reduced vocal inflections, and a diminished ability to express emotions appropriately. Affective flattening is considered a negative symptom because it reflects a decrease or absence of normal emotional functioning.
D. Illogicality: Illogicality, or disorganized thinking, is another positive symptom of schizophrenia. It involves difficulties in organizing thoughts and expressing them coherently. Individuals with schizophrenia may exhibit illogical speech patterns, such as tangentiality (going off on tangents), loose associations (jumping from one unrelated topic to another), or thought blocking (sudden interruption of thoughts).
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