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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Toxoplasmosis: While toxoplasmosis can cause symptoms similar to those described, it is not typically associated with a maculopapular rash on the face. Moreover, routine screening for toxoplasmosis is not typically performed during pregnancy unless indicated by specific risk factors.
B. Group B Streptococcus: Group B Streptococcus is primarily associated with maternal
colonization and neonatal infection, but it does not typically present with a maculopapular rash on the face in the mother.
C. Gonorrhea: Gonorrhea can cause systemic symptoms, but it is not commonly associated with a maculopapular rash on the face. Additionally, routine screening for gonorrhea during pregnancy typically focuses on genital sites rather than systemic symptoms.
D. Rubella: Rubella, or German measles, presents with a maculopapular rash on the face (often described as a "slapped cheek" appearance) along with fever, malaise, sore throat, and
lymphadenopathy. Rubella infection during pregnancy can lead to congenital rubella syndrome, which can have serious consequences for the developing fetus. Therefore, it is important to
review rubella immunity status in pregnant women presenting with these symptoms.
Correct Answer is ["A","B","D","E","G"]
Explanation
A. Acknowledge feelings of anxiety: The client's neurological assessment indicates agitation, and acknowledging this can help in addressing any underlying anxiety.
B. Weigh the client twice weekly: Given the client's low BMI and the mother's concern about her weight, regular monitoring is necessary.
C. Encourage exercise: While exercise is generally healthy, the client's current bradycardia and low BMI suggest that immediate physical exertion may not be advisable without medical
supervision.
D. Provide family education on the condition: The client's mother's concern and the client's defensiveness about her weight indicate a need for family education.
E. Monitor trips to the restroom: Monitoring is important to ensure the client is not engaging in behaviors that could further compromise her health, such as purging.
F.Allow for menu deviations is incorrect. Allowing menu deviations can enable the client to avoid certain foods, which reinforces disordered eating behaviors. Structured, balanced meals are essential for recovery.
G. Set precise mealtimes is correct because establishing structured mealtimes promotes consistency and reduces anxiety related to eating. This helps the client develop healthier eating patterns and decreases the urge to binge or purge.
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