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
This response addresses the client's disrespectful tone and sets a boundary regarding acceptable communication. It promotes respect and professionalism in the nurse-client relationship while addressing the immediate behavior.
B. It maintains a neutral tone and encourages cooperation without escalating the conflict. However, it may come across as slightly confrontational and could potentially provoke further resistance from the client.
C. This response accommodates the client's request to have the schedule provided without further interaction. However, it may reinforce the client's dismissive and disrespectful behavior by complying with their demands without addressing the underlying communication issue.
D. It encourages the client to reflect on their feelings and provides an opportunity for open communication about any issues or concerns they may have. However, it may not be the most effective response in the moment as it could potentially escalate the conflict or lead to further defensiveness from the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.
Correct Answer is C
Explanation
Assessing the client's ability to function is crucial for understanding the impact of grief and depression on their daily life and functioning. Evaluating functional status helps determine the severity of the client's condition and guides interventions to promote recovery and improve quality of life.
A. Spiritual assessment is valuable for understanding the client's beliefs, values, and sources of strength, but it may not directly address the client's current symptoms of grief, depression, and associated sleep disturbances, weight loss, anger, and irritability.
B. While assessing cultural factors is important for providing culturally sensitive care, it may not be the immediate priority compared to addressing the client's symptoms and functional status.
D. Social support plays a significant role in coping with grief and depression. However, while social support is important, the immediate priority may be to address the client's symptoms and functional status.
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