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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently. B. Play loud music for the client in her room. C. Engage the client in a small group activity. D. Instruct the client to avoid napping during the day.

Correct Answer is A

Explanation

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode.

B. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment.

C. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania.

D. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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