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?"

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Alert B. Restless C. Anxiety D. Pacing

Correct Answer is C

Explanation

Anxiety is a subjective emotional state characterized by feelings of worry, nervousness, or unease. If the client reports feeling anxious, this would be considered subjective because it is based on their own perception of their emotional state.

A. Alert refers to the client's level of consciousness and awareness of their surroundings.

B. Restlessness refers to a feeling of agitation or inability to stay still.

D. Pacing is an observable behavior where the client is walking back and forth in the room.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

Correct Answer is C

Explanation

A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

A nurse is teaching a client who is lactose intolerant. Which of the following statements regarding lactose intolerance should the nurse include in the teaching plan?

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a culture different than the nurse. Which of the following statements should the nurse make?

A nurse is providing care to a client who asks, "What is the meaning of holistic nursing care?" The nurse should give which of the following responses?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A 35-year-old woman has been admitted to the hospital for a hysterectomy secondary to uterine cancer caused by smoking, and the nurse is collecting subjective data prior to surgery. Which statements by the nurse could be construed as non-judgmental? (Select All that Apply.)