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

Explanation

Sitting with the client during meals and snacks provides support, encouragement, and supervision to ensure that the client is consuming an adequate amount of food. It also offers an opportunity for the nurse to monitor the client's eating habits, aid if needed.

A. Enrolling the client in a nutritional class may not be the most appropriate action in this situation.

C. While monitoring the client's weight is important for assessing nutritional status and detecting changes over time, weighing the client at the same time every morning may not directly address the underlying issues contributing to malnutrition.

D. While spiritual and emotional support can be beneficial for clients with major depressive disorder, arranging a consultation with the facility chaplain may not directly address the client's nutritional needs or contribute to improving their nutritional status.

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

B. 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.

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. It may increase their distress and hinder their ability to cope with the experience.

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Naxlex Comprehensive Predictor Exams

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

Correct Answer is B

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 obtaining a health history from a client. Which of the following findings should the nurse identify as a non-modifiable risk factor for disease?

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)

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.)

A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

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 manager in a community clinic is explaining the concept of culture to a newly licensed nurse. Which of the following statements should the nurse manager use to describe a subculture?