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 D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

A. Potato chips and diet Coke B. Bagels with cream cheese and tea C. Apple pie and coffee D. Pepperoni pizza and red wine

Correct Answer is D

Explanation

D. Pepperoni pizza and red wine are both high in tyramine and should be avoided when taking MAOIs. The aging and fermentation processes involved in the production of pepperoni and red wine increase the tyramine content, which can lead to a dangerous increase in blood pressure when combined with MAOIs.
A. Potato chips are generally considered safe to eat in moderation with MAOIs, as they do not contain high levels of tyramine. Diet Coke is also considered safe as it does not contain tyramine.
B. Bagels with cream cheese typically do not contain high levels of tyramine, and tea is generally considered safe to consume with MAOIs.
C. Apple pie may contain moderate levels of tyramine, particularly if it contains aged or fermented apples. However, the tyramine content in apple pie is generally not high enough to pose a significant risk when consumed in moderation. Coffee, on the other hand, contains tyramine, but the amount is usually not enough to cause a severe reaction.

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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

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

Correct Answer is D

Explanation

The nurse is caring for a client who is experiencing mania. The client is pacing, cannot sit, and has pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client?

A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?

The nurse is educating clients about recovery from alcohol abuse. Which statement indicates that learning has occurred?

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

A 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

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:

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?