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. Plan the client's schedule to allow time for rituals: This is the most appropriate action. It is essential to recognize that compulsive behaviors in OCD serve as coping mechanisms for the individual. Allowing time for rituals within the client's schedule can help reduce anxiety and provide a sense of control. Gradual exposure and response prevention techniques can be incorporated into the treatment plan over time to help the client gradually decrease reliance on rituals.
B. Isolate the client for a period of time: Isolating the client may exacerbate feelings of anxiety and distress, as well as decrease opportunities for social interaction and support, which are essential components of mental health treatment.
C. Confront the client about the senseless nature of the repetitive behaviors: Confrontation may lead to defensiveness and resistance from the client. It is important to approach the client with empathy and understanding rather than judgment. Educating the client about the nature of OCD and the role of compulsive behaviors in managing anxiety can be more helpful in fostering insight and motivation for change.
D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules: Setting strict limits may increase the client's distress and resistance. It is important to collaborate with the client in treatment planning and find a balance between supporting the client's needs and maintaining a therapeutic environment. Gradual exposure and response prevention techniques should be implemented in a supportive manner rather than through strict enforcement.
Correct Answer is A
Explanation
Rationale:
A) Congenital anomalies: Congenital anomalies, also known as birth defects, are structural or functional abnormalities present at birth. They can affect any part of the body and may cause physical or developmental disabilities, as well as contribute to infant mortality. These anomalies can result from genetic factors, environmental exposures during pregnancy, or a combination of both. Preventive measures such as prenatal care, genetic counseling, and maternal health promotion play crucial roles in reducing the incidence and impact of congenital anomalies.
B) Respiratory distress: While respiratory distress can be a significant concern in newborns, especially those born prematurely or with certain medical conditions, it is not the leading cause of death among infants. Respiratory distress syndrome (RDS) occurs primarily in premature infants due to immature lung development and surfactant deficiency, requiring supportive care and sometimes mechanical ventilation to manage.
C) Sudden infant death syndrome (SIDS): SIDS is the sudden and unexplained death of an otherwise healthy infant, typically occurring during sleep. While SIDS is a devastating tragedy and a major public health concern, it is not the leading cause of death among infants. Strategies to reduce the risk of SIDS include placing infants on their backs to sleep, avoiding soft bedding and overheating, and promoting a safe sleep environment.
D) Low birth weight: Low birth weight, defined as a birth weight of less than 2,500 grams (5.5 pounds), is associated with an increased risk of neonatal complications and long-term health issues. While low birth weight infants may face various health challenges, including respiratory problems and developmental delays, low birth weight itself is not the leading cause of death among infants. Efforts to reduce low birth weight include prenatal care, nutrition support, and management of maternal risk factors such as smoking and substance abuse.
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