A client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by claiming the night shift nurse is aloof and expresses joy to see that, "My favorite nurse is on duty now." Which response is best for the nurse to provide to this client's dichotomous tendency?

"I am happy that you are getting better and will be able to go home."

"Tomorrow I will talk to that nurse about how you were treated last night."

"What did the night nurse do that makes you think the nurse is aloof?"

"I am glad you like me. Which nurse was acting aloof to you?"

Answer and Explanation

The Correct Answer is C

A. "I am happy that you are getting better and will be able to go home.": While positive reinforcement is supportive, it does not address the client’s dichotomous thinking or help them process their perception of the night nurse. It avoids exploring the issue.

B. "Tomorrow I will talk to that nurse about how you were treated last night.": This response reinforces splitting behavior by positioning the nurse as an advocate against a colleague, which may escalate the client’s polarized thinking.

C. "What did the night nurse do that makes you think the nurse is aloof?": This approach encourages the client to reflect on specific behaviors rather than labeling individuals. It helps the client develop insight, reduces dichotomous thinking, and promotes accountability for their perceptions.

D. "I am glad you like me. Which nurse was acting aloof to you?": Combining affirmation with comparison may unintentionally reinforce splitting and favoritism, maintaining the client’s black-and-white perception of others. It does not encourage reflective thinking.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Plumb line test indicates fetal position curvature: This assessment is used to evaluate spinal alignment and posture, not hip integrity. It does not explain asymmetrical buttocks in a newborn.

B. Ortolani maneuver causing a click at the hip joint: A positive Ortolani sign (a “click” or “clunk”) indicates hip dysplasia or subluxation. This finding is significant and should be reported to the healthcare provider for further evaluation and management.

C. Babinski test that reveals fanning out of toes: The Babinski reflex is normal in newborns and does not indicate musculoskeletal abnormality. It is unrelated to asymmetrical buttocks.

D. Moro test precipitating a startle response: The Moro reflex is a normal newborn response and does not indicate hip instability or asymmetry in the buttocks.

A. "When did these voices begin?" B. "Have you taken any hallucinogens?" C. "Are you planning to obey the voices?" D. "Do you believe the voices are real?"

Correct Answer is C

Explanation

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

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Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

Correct Answer is C

Explanation

Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Patient Data Exhibits The nurse is anticipating which additional medications the healthcare provider may prescribe for the client to manage side effects while on morphine sulfate. Select the 3 medications that would be most appropriate to manage the side effects of morphine sulfate.

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.