A nurse is meeting with a 15-year-old client who has ADHD. The client and their parent state they would like their medications stopped due to the unpleasant side effects. Which of the following statements should the nurse make?
Tell me more about what unpleasant effects you have been experiencing
Stop taking the medication immediately
I’ll get the physician to discuss this situation
It’s important to take the medication as prescribed
The Correct Answer is A
a. Tell me more about what unpleasant effects you have been experiencing
Explanation of Choices
Choice A Reason: Tell Me More About What Unpleasant Effects You Have Been Experiencing
This response is the most appropriate because it opens a dialogue between the nurse, the client, and the parent. Understanding the specific side effects the client is experiencing allows the nurse to gather detailed information, which is crucial for assessing the situation accurately. This approach shows empathy and concern for the client’s well-being and can help identify whether the side effects are manageable or if an alternative treatment plan is needed. It also ensures that the client feels heard and supported.
Choice B Reason: Stop Taking the Medication Immediately
Advising the client to stop taking the medication immediately is not appropriate without a thorough assessment and consultation with the prescribing physician. Abruptly discontinuing ADHD medication can lead to withdrawal symptoms and a resurgence of ADHD symptoms, which can negatively impact the client’s daily functioning and overall health. Medication changes should always be made under medical supervision to ensure safety and effectiveness.
Choice C Reason: I’ll Get the Physician to Discuss This Situation
While involving the physician is an important step, this response alone does not address the immediate concerns of the client and parent. It is essential for the nurse to first understand the specific issues before referring to the physician. This ensures that the physician has all the necessary information to make an informed decision about the client’s treatment plan. Additionally, this response may come across as dismissive if not coupled with an initial assessment by the nurse.
Choice D Reason: It’s Important to Take the Medication as Prescribed
While it is true that taking medication as prescribed is important, this response does not acknowledge the client’s and parent’s concerns about side effects. It may come across as dismissive and could damage the trust between the client, parent, and healthcare provider. Addressing the side effects and exploring possible solutions or alternatives is crucial for maintaining adherence to the treatment plan and ensuring the client’s well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. Splitting.
Choice A Reason: Denial
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. While denial can be present in various mental health conditions, it does not specifically explain the client’s sudden shift from idealizing to devaluing the nurse.
Choice B Reason: Separation-individuation
Separation-individuation refers to a developmental process where an individual differentiates themselves from others, particularly caregivers, and develops a sense of self. This concept is more relevant to early childhood development and does not directly explain the client’s behavior in this context.
Choice C Reason: Reaction formation
Reaction formation is a defense mechanism where an individual expresses feelings or behaviors that are opposite to their true feelings or desires. While this can occur in borderline personality disorder, it does not fully capture the client’s extreme shift in perception from positive to negative.
Choice D Reason: Splitting
Splitting is a hallmark characteristic of borderline personality disorder. It involves viewing people or situations in black-and-white terms, as either all good or all bad, with no middle ground. The client’s outburst, shifting from idealizing the nurse to seeing them as hateful, is a classic example of splitting. This defense mechanism helps individuals with borderline personality disorder manage their intense emotions and fears of abandonment.
Correct Answer is B
Explanation
The correct answer is b. Generates conflict among the staff.
Choice A Reason:
Bizarre speech patterns are not typically associated with borderline personality disorder (BPD). BPD is characterized by intense emotional responses, unstable relationships, and impulsive behaviors. While individuals with BPD may exhibit erratic behavior, bizarre speech patterns are more commonly linked to disorders such as schizophrenia.
Choice B Reason:
Generating conflict among the staff is a behavior pattern often observed in individuals with borderline personality disorder. People with BPD may have difficulty maintaining stable relationships and can exhibit manipulative behaviors, leading to conflicts. This behavior stems from their intense fear of abandonment and efforts to avoid real or perceived rejection.
Choice C Reason:
Social isolation is not a primary characteristic of borderline personality disorder. While individuals with BPD may experience intense and unstable relationships, they typically do not isolate themselves socially. Instead, they may engage in intense and tumultuous interactions with others.
Choice D Reason:
Suspiciousness of others is more commonly associated with paranoid personality disorder rather than borderline personality disorder. While individuals with BPD may have trust issues and fear abandonment, their behavior is more characterized by emotional instability and impulsive actions rather than pervasive suspiciousness.
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