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. Provide a small electronic toy.
Providing a small electronic toy can engage the infant's senses and promote cognitive development. Interactive toys can stimulate the infant's curiosity, encourage exploration, and provide sensory stimulation, which are important aspects of infant development. However, the selection of toys should consider safety and age appropriateness, ensuring they do not pose a choking hazard or contain small parts that the infant could ingest.
B. Change the infant's diaper as soon as soiling occurs.
Changing the infant's diaper promptly when soiling occurs is essential for maintaining hygiene and preventing skin irritation or infection. However, while diaper changes are necessary for the infant's comfort and well-being, they primarily address basic needs rather than directly promoting growth and development related to the hip dysplasia.
C. Allow the infant to stand in the crib.
Allowing the infant to stand in the crib may not be suitable, especially if the infant is in a cast for developmental dysplasia of the hip (DDH). The cast is typically intended to maintain the hip joint in a specific position to promote proper alignment and development. Allowing the infant to stand in the crib could compromise the effectiveness of the treatment and potentially exacerbate the hip dysplasia. Therefore, this option is not appropriate.
D. Tie colorful latex balloons to the side of the crib.
Tying colorful latex balloons to the side of the crib is not recommended due to safety concerns. Latex balloons pose a choking hazard if they deflate or rupture, and the infant could accidentally ingest the latex material, leading to airway obstruction or other complications. Safety is paramount in infant care, and any potential hazards should be avoided.
Correct Answer is B
Explanation
A. The client drinks 2 liters of liquids daily: Adequate hydration is important when taking lithium to prevent dehydration, which can increase lithium levels. Drinking 2 liters of liquids daily is appropriate and helps maintain hydration, reducing the risk of lithium toxicity.
B. The client runs 4 miles outdoors every afternoon: Vigorous exercise and excessive sweating, such as running 4 miles outdoors daily, can lead to dehydration and increased lithium levels, thereby increasing the risk of lithium toxicity. Clients taking lithium should be advised to avoid excessive sweating and to maintain adequate hydration during exercise.
C. The client eats 2 to 3 gm of sodium-containing foods daily: Consuming sodium-containing foods helps prevent lithium toxicity by promoting lithium excretion through the kidneys. Adequate sodium intake is necessary to maintain lithium balance in the body. Eating 2 to 3 grams of sodium-containing foods daily is within the recommended range for clients taking lithium.
D. The client eats foods high in tyramine: Foods high in tyramine are associated with the risk of hypertensive crisis, particularly in clients taking monoamine oxidase inhibitors (MAOIs), not lithium. While dietary restrictions may be necessary for clients taking MAOIs, they are not relevant to lithium therapy.
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