A client who has 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?
"What did the night nurse do that makes you think the nurse is aloof?"
"Tomorrow I will talk to that nurse about how you were treated last night."
"I am happy that you are getting better and will be able to go home."
"I am glad you like me. Which nurse was acting aloof to you?"
None
None
The Correct Answer is A
Choice A reason: This response invites the client to describe specific behaviors, promoting reality testing and reducing global judgments. It shifts the focus to observable facts, encourages problem solving, and sets a neutral, nonjudgmental tone that helps manage splitting without taking sides or reinforcing dichotomous thinking.
Choice B reason: Promising to speak to the other nurse takes the nurse’s role beyond immediate assessment and may reinforce the client’s splitting by implying advocacy against staff. It avoids eliciting specifics, delays direct exploration of the client’s perception, and can undermine professional boundaries and accountability.
Choice C reason: Offering general reassurance about discharge does not address the client’s immediate interpersonal splitting or the complaint about the night nurse. It sidesteps the behavior, misses an opportunity for clarification, and fails to help the client examine or verbalize the concrete reasons behind their polarized view.
Choice D reason: Responding with flattery while asking which nurse was aloof can validate the client’s splitting and encourage manipulation or favoritism. It risks reinforcing the “favorite” dynamic and does not promote objective description of events or help the client process feelings in a therapeutic, boundary‑maintaining way.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
Correct Answer is A
Explanation
Choice A reason: The priority is to manage the client's severe pain, which can be achieved through the administration of an IV analgesic. Effective pain management is crucial for postoperative recovery and can prevent complications related to increased pain, such as elevated heart rate and blood pressure.
Choice B reason: While assessing the IV site for patency is important, it is not the most critical intervention when a client is experiencing severe pain.
Choice C reason: Providing a pillow for splinting can help with pain management during movement or coughing but does not directly address the immediate need for pain relief.
Choice D reason: Placing the client in a high-Fowler's position may aid in comfort and breathing but is not the most important intervention for severe pain management.

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