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 B
Explanation
A. Administer opioids for pain:
While pain management is crucial after surgery, opioids may not be the first-line choice for pain relief in toddlers due to their potential side effects, including respiratory depression and sedation. Non-opioid pain relief methods such as acetaminophen or ibuprofen may be preferred, depending on the toddler's age and the surgeon's preference.
B. Apply bilateral wrist restraints:
After a cleft palate repair, it's essential to prevent the toddler from putting hands or objects into their mouth, as this could disrupt the surgical site and compromise healing. Bilateral wrist restraints help to immobilize the toddler's arms and prevent them from reaching the mouth area, reducing the risk of injury and promoting healing.
C. Implement a soft diet:
A soft diet may be appropriate for the toddler once they have fully recovered from the surgery and the surgical site has healed adequately. However, 24 hours postoperative is too soon to introduce a soft diet, as the toddler may still be recovering from anesthesia and experiencing discomfort. It's essential to follow the surgeon's orders regarding diet progression.
D. Offer fluids through a straw:
Offering fluids through a straw may pose a risk of aspiration or injury to the surgical site, especially in the immediate postoperative period. It's crucial to follow the surgeon's instructions regarding feeding methods and avoid using straws until the toddler has fully recovered and the surgical site has healed.
Correct Answer is C
Explanation
A. "I will feed my baby on a schedule every 4 hours": Feeding an infant with heart failure on a strict schedule may not be appropriate because it may not allow the infant to consume adequate calories and nutrients when needed. Infants with heart failure may tire easily during feeding, so they may require more frequent, smaller feedings to ensure adequate intake.
B. "I will add Polycose to each of my baby's bottles": Polycose is a carbohydrate supplement sometimes used to increase the calorie content of infant formula or breast milk. However, adding it to every bottle without guidance from a healthcare provider may not be necessary or appropriate. The decision to use Polycose should be based on the infant's specific nutritional needs and should be directed by the healthcare team.
C. "I will allow my baby to take as much time as needed to finish the bottle": This statement indicates an understanding that infants with heart failure may have difficulty feeding due to fatigue or respiratory distress. Allowing the baby to take as much time as needed to finish the bottle ensures that they can consume an adequate amount of milk without becoming exhausted.
D. "I will limit my baby's crying to 15 minutes prior to each feeding": Limiting the baby's crying before feeding is not directly related to meeting the infant's nutritional needs. While minimizing stress and agitation before feeding can be beneficial, setting a specific time limit on crying may not always be practical or effective.
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