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 A
Explanation
A. Assist the client to the correct room: This option addresses the immediate safety concern by guiding the client back to their own room, reducing distress for both the client and the other resident. It promotes dignity and minimizes the risk of agitation or further disruptive behavior.
B. Place the client in restraints: Restraints should only be used as a last resort for safety when all other measures have been exhausted and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful to individuals with Alzheimer's disease and should not be used unless absolutely necessary.
C. Reorient the client to time and place: Reorientation may not be effective for clients with advanced Alzheimer's disease, as their cognitive impairments may limit their ability to understand or retain this information. Additionally, reorientation may not address the immediate safety concern posed by the client's behavior.
D. Move the client to a room at the end of the hall: While this option may be considered in some situations to minimize disruption to other residents, it does not address the underlying issue of the client's confusion or wandering behavior. Additionally, moving the client may cause further distress and confusion.
Correct Answer is D
Explanation
A. Playing a game of chess with the client: While engaging in activities with the client can be therapeutic, it's essential to consider the client's preferences and level of interest. Some clients with severe depression may not have the motivation or energy to participate in activities like playing chess. Additionally, the focus should be on providing support and empathy rather than suggesting specific activities.
B. Giving the client choices of activities: Offering choices of activities can empower the client and promote autonomy, which is beneficial. However, individuals with severe depression may struggle with decision-making and may feel overwhelmed by choices. Therefore, while offering choices can be therapeutic, it's essential to provide support and guidance in decision-making if needed.
C. Encouraging decision-making: Encouraging decision-making can be beneficial for clients with depression as it promotes a sense of control and self-efficacy. However, individuals with severe depression may find decision-making challenging due to feelings of hopelessness or low energy levels. Therefore, while encouraging decision-making, it's essential to provide support and assistance as needed.
D. Spending time sitting with the client: This is the most therapeutic approach listed. Spending time with the client provides emotional support, companionship, and a nonjudgmental presence, which can be invaluable for someone experiencing severe depression. Simply being present and available to listen without pressure to talk or engage in activities can convey empathy and understanding, fostering a therapeutic nurse-client relationship.
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