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. Diphenhydramine is an antihistamine and is not typically used to manage opiate withdrawal. It may help with certain symptoms like insomnia or mild anxiety but is not a primary treatment for opioid withdrawal.
B. Methadone is commonly used in the treatment of opioid withdrawal. It is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, providing a more controlled tapering process. Methadone is often used in medication-assisted treatment (MAT) for opioid use disorder.
C. Benzodiazepines are not typically used as the first-line treatment for opioid withdrawal. They may be considered in specific situations, such as when there is severe anxiety or agitation, but they are generally not the primary choice due to the risk of dependence.
D. Naloxone is an opioid antagonist used to reverse opioid overdose. It is not used in the routine management of opioid withdrawal but rather in emergency situations where opioid overdose is suspected.
Correct Answer is C
Explanation
A. "A single dose of diazepam is unlikely to cause side effects" is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness.
B. "Grapefruit juice inactivates this medication" is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam.
C. "Diazepam can cause drowsiness" is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents.
D. "Avoid foods that contain tyramine" is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.
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