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","C","D","E"]
Explanation
A. Spinning a toy repetitively: Repetitive behaviors, such as spinning objects or repetitive movements, are common in children with ASD. These behaviors often serve as self-stimulatory or soothing activities and may be used as a way to cope with sensory stimulation or to seek sensory input.
B. Consistent limit testing: While limit testing can occur in children with ASD, it is not a specific hallmark of the disorder. Limit testing is more commonly associated with typical developmental behavior or oppositional defiant disorder rather than ASD.
C. Ritualistic behavior: Children with ASD often engage in ritualistic or repetitive behaviors, such as adhering to strict routines or rituals, having specific preferences for how objects are arranged, or engaging in repetitive movements or actions. These behaviors can provide a sense of predictability and control in their environment.
D. Short attention span: Many children with ASD have difficulty sustaining attention and may exhibit a short attention span, particularly in tasks that do not align with their specific interests or preferences. However, attention span can vary widely among children with ASD, and some may have exceptional focus on particular activities or topics of interest.
E. Delayed language development: Delayed language development is a common characteristic of ASD. Some children with ASD may experience delays in acquiring spoken language skills, exhibit echolalia (repetition of words or phrases), or have difficulty with expressive and receptive language. However, it's important to note that language development can vary significantly among individuals with ASD, and some may have average or even advanced language skills.
Correct Answer is B
Explanation
A. Increased urinary output: Acute lead poisoning typically does not lead to increased urinary output. Instead, lead toxicity can affect renal function, potentially leading to kidney damage and decreased urinary output or even renal failure in severe cases.
B. Anorexia: Acute lead poisoning can lead to gastrointestinal symptoms such as abdominal pain, nausea, and vomiting, which can result in decreased appetite or anorexia. Lead poisoning affects multiple organ systems, including the gastrointestinal tract, leading to symptoms like abdominal pain and gastrointestinal upset. Anorexia is a common manifestation in individuals, including toddlers, with acute lead poisoning due to these gastrointestinal symptoms.
C. Jaundice: Jaundice is not a typical finding in acute lead poisoning. Jaundice typically occurs when there is an accumulation of bilirubin in the blood, which can be caused by liver dysfunction or obstruction of the bile ducts. Lead poisoning primarily affects the central nervous system, hematopoietic system, and gastrointestinal system rather than the liver.
D. Diarrhea: While gastrointestinal symptoms such as abdominal pain, nausea, and vomiting can occur in acute lead poisoning, diarrhea is not a characteristic symptom. Lead poisoning can cause constipation rather than diarrhea due to its effects on the gastrointestinal tract, such as slowing peristalsis.
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