A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

"I'm glad you feel comfortable with me."

"I am sorry I cannot be your friend."

"You feel other's don't understand you?"

"I'm here to help you just as all the staff members are."

Answer and Explanation

The Correct Answer is D

D. It acknowledges the client’s comfort while emphasizing the nurse’s professional role. It sets clear boundaries and reinforces that the nurse’s primary purpose is to provide care and support within the therapeutic context.

A. This response acknowledges the client’s feelings but does not set clear boundaries. It may

inadvertently encourage the client to view the nurse as a friend rather than a professional caregiver.

B. While this response establishes boundaries, it may come across as abrupt or cold. It lacks empathy and understanding.

C. This response reflects empathy and encourages further exploration of the client’s feelings. However, it does not address the professional boundaries explicitly.

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Correct Answer is C

Explanation

C. A neutral attitude communicates respect, professionalism, and non-threatening intentions. It helps to minimize the client's feelings of being scrutinized or manipulated and creates a safe environment for the client to engage in therapeutic interactions.

A. Disclosing personal information may further exacerbate the client's mistrust and suspicion, as they may interpret it as confirmation of their paranoid beliefs or as an attempt to manipulate them.

B. Approaching the client frequently throughout the day may be overwhelming and increase the client's suspicion. Clients with paranoid personality disorder often feel threatened by perceived intrusions into their personal space or privacy.

D. While it's essential to respect the client's autonomy and boundaries, waiting for the client to initiate interaction may prolong the establishment of a therapeutic relationship, especially with a client who is suspicious and mistrustful.

A. A monoamine oxidase inhibitor (MAOI) B. A selective serotonin reuptake inhibitor (SSRI) C. A tricyclic antidepressant (TCA) D. An atypical antipsychotic E. None F. None

Correct Answer is A

Explanation

A. MAOIs are a class of antidepressants that work by inhibiting the activity of monoamine oxidase, an enzyme that breaks down neurotransmitters such as serotonin, dopamine, and norepinephrine. MAOIs can interact with certain foods and other medications, potentially leading to a hypertensive crisis characterized by severe hypertension, headache, diaphoresis, and other symptoms.
B. SSRIs are commonly prescribed antidepressants that work by increasing the levels of serotonin in the brain. Serotonin syndrome can present with symptoms such as headache, diaphoresis, tachycardia, and hyperthermia, but it typically doesn't cause severe hypertension.
C. TCAs are another class of antidepressants that work by inhibiting the reuptake of serotonin and norepinephrine. TCAs can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention. However, TCAs are less commonly associated with severe hypertension compared to MAOIs.
D. Atypical antipsychotics are used to treat various psychiatric disorders, including schizophrenia and bipolar disorder. While they are not typically associated with causing severe hypertension directly, they can have cardiovascular side effects such as tachycardia and orthostatic hypotension.

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A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with paranoid personality disorder who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

Which are common reasons why abused persons remain with an abusive partner? Select all that apply.

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is caring for a client who has major depressive disorder and was prescribed fluoxetine 2 weeks ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

A nurse is providing teaching to a client who has schizophrenia and is to begin taking haloperidol. Which of the following information should the nurse include in the teaching?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?