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. "I use a suppository every night to have a bowel movement": This statement indicates an appropriate understanding of managing bowel function, as regular bowel movements are essential for individuals with spinal cord injury to prevent complications such as constipation.
B. "I only need to catheterize myself twice every day": Individuals with spinal cord injury and paralysis often require intermittent catheterization at regular intervals to empty their bladders completely and prevent urinary retention. Twice-daily catheterization may not be sufficient for adequate bladder management and could lead to urinary complications such as urinary tract infections or bladder overdistention. The client may need further teaching to understand the importance of more frequent catheterization.
C. "I carry a water bottle with me because I drink a lot of water": Staying hydrated is crucial for individuals with spinal cord injury to prevent urinary tract infections and maintain overall health. Carrying a water bottle indicates an appropriate understanding of the importance of hydration.
D. "I do wheelchair exercises while watching TV": Engaging in wheelchair exercises is beneficial for maintaining strength, mobility, and overall health for individuals with spinal cord injury. This statement demonstrates an understanding of the importance of physical activity and exercise in the client's daily routine.
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