As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?
I know you can read it yourself, but will you?"
"We do this every day. Why are you so angry with me this morning?
“I expect you to speak to me in a civil tone of voice."
Fine. Here is the schedule. I expect you to be on time for your therapy sessions.
The Correct Answer is C
A. "I know you can read it yourself, but will you?" This response may escalate the situation and may not effectively address the inappropriate tone. It also has the potential to be perceived as confrontational.
B. "We do this every day. Why are you so angry with me this morning?" This response is somewhat confrontational and may not be as effective in setting clear boundaries. It also focuses on the client's emotion without directly addressing the inappropriate tone.
C. “I expect you to speak to me in a civil tone of voice."
Option C sets clear boundaries and communicates the expectation of respectful communication. Addressing the inappropriate tone of voice is important in working with individuals with borderline personality disorder. It reinforces the importance of maintaining a therapeutic and respectful interaction.
D. "Fine. Here is the schedule. I expect you to be on time for your therapy sessions." While this response provides the information, it doesn't address the issue of the client's disrespectful tone. It's important to address the inappropriate behavior while still providing necessary information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperexcitability is not typically associated with major depressive disorder. In fact, individuals with depression often experience a decrease in energy, motivation, and overall activity levels.
B. Significant change in weight.
Major depressive disorder (MDD) is often associated with changes in appetite and weight. Clients with MDD may experience either weight loss or weight gain. This can result from changes in eating habits related to the individual's emotional state.
C. Exaggerated response of pleasure to stimuli is not a characteristic finding in major depressive disorder. In contrast, individuals with depression may experience anhedonia, which is a reduced ability to experience pleasure from previously enjoyable activities.
D. Attention-seeking behavior is not a specific characteristic of major depressive disorder. Individuals with depression may withdraw socially and experience difficulties in concentration and attention.
Correct Answer is D
Explanation
A. "You may experience muscle cramping from the induced seizure." While muscle stiffness is possible, the term "muscle cramping" might not accurately describe the postictal state after ECT.
B. "The most common adverse effects of ECT are related to anesthesia." While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients.
D. "You might feel a bit confused and disoriented when you first wake up." This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.
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