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 D
Explanation
A. Place the infant in an infant seat for 2 hours following the procedure. There is no specific need to place the infant in an infant seat for 2 hours following a lumbar puncture. After the procedure, the infant should be positioned comfortably and safely, but there is no requirement for a specific duration in an infant seat.
B. Hold the infant's chin to his chest and knees to his abdomen during the procedure. This positioning is not appropriate for a lumbar puncture. The correct positioning for a lumbar puncture involves having the infant in a lateral recumbent (side-lying) position with knees flexed up toward the chest, allowing the spine to be flexed and creating space between the vertebrae for the needle insertion.
C. Keep the infant NPO for 6 hours prior to the procedure. Keeping the infant NPO (nothing by mouth) for 6 hours prior to the procedure is not necessary for a lumbar puncture. Infants can continue breastfeeding or formula feeding as usual before the procedure. However, if sedation or anesthesia is planned for the procedure, specific fasting guidelines may apply depending on institutional protocols and the infant's age and health status.
D. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 minutes prior to the procedure. This is the correct choice. Applying a eutectic mixture of lidocaine and prilocaine cream topically before the procedure helps to numb the skin and reduce pain at the site of the lumbar puncture. It is a standard practice to minimize discomfort for the infant during the procedure.
Correct Answer is C
Explanation
A. Providing support for family and friends following a suicide:
Providing support for family and friends following a suicide is an example of a tertiary intervention. Tertiary interventions focus on providing support, counseling, and resources to individuals affected by suicide after the event has occurred, aiming to prevent further emotional distress, promote healing, and reduce the risk of additional suicides in the community.
B. Recognizing the warning signs of suicide:
Recognizing the warning signs of suicide is an example of a primary intervention. Primary interventions aim to prevent suicide by identifying individuals at risk and intervening before a suicide attempt occurs. Educating healthcare professionals and the community about the warning signs of suicide is crucial for early identification and intervention.
C. Performing life-saving measures following a suicide attempt:
This is an example of a secondary intervention. Secondary interventions involve actions taken after the occurrence of a suicide attempt or completed suicide to prevent further harm or loss of life. Performing life-saving measures, such as cardiopulmonary resuscitation (CPR) or providing emergency medical care, falls under secondary interventions because it occurs after the suicide attempt to mitigate the immediate physical consequences.
D. Identifying individuals who are at higher risk for attempting suicide:
Identifying individuals who are at higher risk for attempting suicide is also an example of a primary intervention. This involves screening, assessment, and risk evaluation to identify individuals with risk factors and warning signs of suicide, allowing for targeted interventions, support, and prevention strategies to be implemented before a suicide attempt occurs.
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