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?
"Fine.
"I don't like it when you address me with that tone of voice."
"We do this every day.
"I know you can, but are you going to read it or not?" .
re is the schedule, and I will expect you to be on time to your therapies."
The Correct Answer is B
Choice A rationale:
Avoids addressing the client's behavior: This response does not directly address the client's disrespectful tone of voice. It simply gives the client the schedule and expects them to comply. This could reinforce the client's belief that they can act out without consequences.
Misses an opportunity to set boundaries: Setting boundaries is essential when working with clients with BPD. This response does not establish a clear boundary regarding acceptable communication.
Does not promote therapeutic communication: This response does not encourage the client to share their feelings or explore the reasons behind their outburst. It shuts down communication rather than opening it up.
Choice B rationale:
Directly addresses the inappropriate behavior: This response assertively communicates to the client that their tone of voice is unacceptable. It sets a clear boundary regarding respectful communication.
Models appropriate communication: The nurse models respectful communication by using a calm and assertive tone of voice. This can help the client learn to communicate more effectively.
Promotes self-awareness: This response may prompt the client to reflect on their behavior and the impact it has on others. It can help them develop better self-awareness and emotional regulation skills.
Choice C rationale:
Focuses on the nurse's feelings: This response shifts the focus away from the client's behavior and onto the nurse's feelings. It can make the client feel defensive and less likely to engage in productive communication.
May escalate the situation: Asking "why" s can sometimes put clients on the defensive and lead to further conflict. It's generally more helpful to focus on the present behavior and its impact.
Choice D rationale:
Condescending and challenging: This response comes across as condescending and challenging. It's likely to make the client feel defensive and resentful.
Not therapeutic: This response does not promote a sense of trust or rapport between the nurse and the client. It's unlikely to lead to productive communication or behavior change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F"]
Explanation
Choice A rationale:
Personality disorders are not typically considered to be comorbidities of eating disorders. While some personality traits, such as perfectionism and obsessiveness, may be more common in individuals with eating disorders, these traits do not necessarily
constitute a personality disorder. Additionally, the presence of a personality disorder does not typically increase the risk of developing an eating disorder.
Choice B rationale:
Depression is one of the most common comorbidities associated with eating disorders. Studies have shown that up to 50% of individuals with eating disorders also experience depression. The relationship between eating disorders and depression is complex and bidirectional. Depression can contribute to the development of an eating disorder, and the behaviors associated with eating disorders can also worsen depression.
Choice C rationale:
Breathing-related sleep disorders, such as obstructive sleep apnea, are not typically associated with eating disorders. While some individuals with eating disorders may experience sleep disturbances, these disturbances are more likely to be related to other factors, such as anxiety or depression.
Choice D rationale:
Obsessive-compulsive disorder (OCD) is another common comorbidity of eating disorders. Studies have shown that up to 30% of individuals with eating disorders also have OCD. The symptoms of OCD, such as obsessive thoughts and compulsive behaviors, can overlap with the symptoms of eating disorders. For example, an individual with OCD may have obsessive thoughts about food and weight, and they may engage in compulsive behaviors related to eating, such as calorie counting or food restriction.
Choice E rationale:
Schizophrenia is not typically associated with eating disorders. While some individuals with schizophrenia may experience disturbances in eating behavior, these disturbances are more likely to be related to other symptoms of the disorder, such as delusions or hallucinations.
Choice F rationale:
Anxiety is another common comorbidity of eating disorders. Studies have shown that up to 60% of individuals with eating disorders also experience anxiety disorders. Anxiety can contribute to the development of an eating disorder, and the behaviors associated with eating disorders can also worsen anxiety.
Correct Answer is C
Explanation
Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.
However, it’s not the most critical vital sign to address first in this scenario.
Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.
However, it’s not the most immediate concern compared to other vital signs.
Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.
Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.
Therefore, it should be addressed first.
Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.
However, it’s not the most immediate concern in this scenario.
In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.
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