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 C
Explanation
A. Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia.
B. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation.
C. Pupillary constriction (miosis).
Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness.
D. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.
Correct Answer is D
Explanation
A. Stating that the medication will prevent depression is not accurate. Risperidone primarily addresses symptoms of psychosis and does not specifically target depression.
B. Indicating that the medication will improve mood is not the primary purpose of risperidone. Its focus is on managing psychotic symptoms rather than directly impacting mood.
C. Mentioning that the medication will decrease anxiety is not the primary action of risperidone. While it might indirectly reduce anxiety associated with psychotic symptoms, it's not its primary function.
D. "This medication will clear your thinking."
Risperidone is an antipsychotic medication commonly used to manage symptoms of schizophrenia, including hallucinations, delusions, and disorganized thinking. While it won't directly improve mood, decrease anxiety, or prevent depression, it aims to alleviate symptoms related to psychosis, allowing for clearer and more organized thinking by reducing hallucinations and delusions.
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