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."

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

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

Answer and Explanation

The Correct Answer is A

A. "I am happy that you are getting better and will be able to go home."
This response focuses on the client’s progress and avoids engaging with their polarized views. It provides positive reinforcement and shifts the focus toward recovery.

B. "Tomorrow I will talk to that nurse about how you were treated last night."
This could escalate the situation and may inadvertently validate the client's idealization or devaluation of others, without fully understanding the dynamics.

C. "I am glad you like me. Which nurse was acting aloof to you?"
This response reinforces the client’s idealization of the current nurse, which could perpetuate dichotomous thinking.

D. "What did the night nurse do that makes you think the nurse is aloof?"
This invites the client to focus on negative perceptions of the night nurse, potentially escalating their emotional instability.

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Correct Answer is A

Explanation

A. Liquid brown drainage from the stoma is abnormal and could indicate bowel content leakage, suggesting a potential connection between the bowel and the conduit or possible infection. This is a critical finding and should be reported immediately.

- B: A stomal output of 40 mL in the last hour is within normal limits postoperatively, as urine production can vary and this amount does not suggest acute complications.

C. A red and edematous stomal appearance is normal in the immediate postoperative period and indicates adequate blood supply to the stoma.

- D: Mucous strings in the drainage are normal because mucus is produced by the intestinal lining, which is now part of the urinary diversion. This is an expected finding and not a cause for immediate concern.

A. Instruct the client on the importance of notifying sexual partners. B. Notify that persons with STIs are reported to local health departments. C. Discuss that partners without similar symptoms may not be infected. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is A

Explanation

A. Instructing the client on the importance of notifying sexual partners is essential to prevent the spread of genital herpes and other sexually transmitted infections. Partner notification is crucial for their testing, treatment, and prevention of further transmission.
B. While it is true that cases of certain STIs are reportable to local health departments, focusing solely on reporting does not address the immediate concern of preventing transmission to sexual partners.
C. While partners without symptoms may not be infected, they could still be carriers of the virus and transmit it to others. It's important to emphasize the potential risk of transmission regardless of symptoms.
D. Counseling that most contraceptives protect against infection is inaccurate regarding STIs.
While contraceptives may prevent pregnancy, they do not provide protection against STIs like genital herpes. It's important to provide accurate information about STI prevention methods.

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Naxlex Comprehensive Predictor Exams

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is A

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is A

Explanation

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for family. Which information is most important for the nurse to obtain?

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?