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 A

Explanation

Ask the client to bring all the medications and supplements to an interview involves direct visual confirmation of all medications and supplements the client is currently taking. It allows the nurse to verify the actual medications being used, including prescription medications from multiple providers, over-the-counter medications, and supplements.
B. While caregivers can provide valuable information about the client's medication regimen, relying solely on their input may not always be accurate.
C. While it provides information about daily medications, it may not capture medications taken on an as- needed basis or those prescribed intermittently.
D. Inquiring about over-the-counter medications is essential as they can interact with prescribed medications and affect the overall medication regimen. However, this method alone may not capture the entirety of the client's medication regimen, particularly prescription medications from multiple providers.

A. Assess the child without their caregiver present. B. Have toys or drawing materials available for the child. C. Focus on the physical domain of health. D. Have the child carefully repeat the events of the trauma.

Correct Answer is B

Explanation

Providing toys or drawing materials can help the child express their thoughts, feelings, and experiences in a nonverbal and developmentally appropriate manner. Play-based activities allow children to communicate and process their emotions more comfortably than verbal communication alone.

A. For young children, especially those who have experienced trauma, the presence of a caregiver can provide comfort, reassurance, and support during the assessment process.

C. Neglecting the child's emotional needs can result in overlooking important aspects of their experience and hinder their recovery.

D. Asking the child to repeat the events of the trauma can be retraumatizing and overwhelming for them.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

Correct Answer is A

Explanation

A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client

Correct Answer is B

Explanation

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

A community health nurse is making efforts to expand their cultural competence when working with clients. To develop cultural competence, the nurse must appreciate understand which of the following characteristics of their clients?

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

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 interviewing a client who is contemplating a behavior change. According to the processes of Motivational Interviewing, which of the following client behaviors indicates that the nurse has successfully engaged with the client?

A nurse is precepting a student nurse interviewing a client with a different cultural background. Which nonverbal behavior by the student indicates that the nurse should intervene? (Select all that apply)