The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

denial.

separation-individuation.

splitting.

reaction formation.

Answer and Explanation

The Correct Answer is C

C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.

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Correct Answer is B

Explanation

B. Tricyclic antidepressants (TCAs) are known to take some time before their full therapeutic effects are realized, which can indeed be up to four weeks. This delay is due to the gradual changes they induce in the brain's biochemistry.
A. TCAs can cause a variety of side effects but hypomania and recent memory impairment are not typically associated with these medications.
C. TCAs do not have a known interaction with antianxiety agents that would prohibit their concurrent use.
D. The restriction on eating strong or aged cheese is associated with another class of antidepressants known as monoamine oxidase inhibitors (MAOIs), not TCAs.

A. Insert a nasogastric tube B. Monitor airway and vital signs C. Insert an indwelling urinary catheter or monitor output D. Anticipate and treat hyperpyrexia with cooling measures

Correct Answer is B

Explanation

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

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The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

Correct Answer is B

Explanation

The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Correct Answer is B

Explanation

A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

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