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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Tremors: Benztropine is an anticholinergic used to reduce tremors in Parkinson’s disease, so tremors are not an expected adverse effect of this medication.
B. Urinary retention: Anticholinergic effects of benztropine can decrease bladder contractility, leading to urinary retention, which is a common side effect that clients should monitor.
C. Blurred vision: Benztropine can cause blurred vision due to its anticholinergic effect on the eyes, including pupillary dilation and impaired accommodation. Clients should be cautioned about visual changes.
D. Diarrhea is uncommon with benztropine; in fact, anticholinergic medications more often cause constipation rather than diarrhea.
E. Drooling: Benztropine reduces salivation, so drooling is not expected. The medication may actually help decrease excessive salivation associated with Parkinson’s disease.
Correct Answer is B
Explanation
A. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: While verifying a DNR order is important, not all advance directives are represented by a bracelet. This action alone does not clarify the client’s wishes or the specifics of the living will.
B. Seek clarification of the type of advance directive the client has: Living wills and other advance directives vary in scope and specificity. Confirming the type of directive ensures that care aligns with the client’s legally documented wishes and guides future interventions appropriately.
C. Explain that living wills cannot be followed by emergency personnel: Emergency personnel can follow advance directives if they are clearly documented and accessible. Saying they cannot be followed is inaccurate and may create mistrust with the family.
D. Schedule a client and family conference to review the plan of care: A conference may be helpful later for education and care planning, but it does not address the immediate need to clarify the client’s specific directives after an emergency intervention.
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