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 D

Explanation

D. The constant repetitive cleaning behavior observed in the client with OCD is likely an attempt to decrease anxiety associated with obsessive thoughts or fears of contamination.

A. While individuals with OCD may engage in compulsive behaviors to gain a sense of control over their environment, the primary motivation behind these behaviors is not to manipulate others.

B. While engaging in repetitive cleaning behaviors may occupy the client's time and attention, the primary purpose of these behaviors is not necessarily to decrease the time available for interaction with people.

C. While individuals with OCD may experience distress or anxiety related to their obsessions and may engage in compulsive behaviors to reduce these feelings, the goal is typically to alleviate anxiety

A. A child who uses the call light frequently B. A child whose parents answer questions for the child C. A child who has a BMI indicating obesity D. A child who has frequent visitors

Correct Answer is B

Explanation

B. This behavior may be concerning if it indicates a lack of autonomy or control over one's own communication. It could suggest overprotective or controlling behavior by the parents, which may be indicative of emotional abuse or neglect.

A. Frequent use of the call light may indicate a need for assistance or discomfort but does not necessarily indicate abuse. It could be related to the child's medical condition, anxiety, or other factors.

C. Childhood obesity itself is not necessarily indicative of abuse. It can result from a variety of factors, including genetics, dietary habits, and lifestyle factors.

D. Frequent visitors alone do not necessarily indicate abuse. However, it's important to consider the nature of the visitors' relationship with the child and whether they may pose a risk of harm.

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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 home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is exploring treatment options with a client addicted to heroin. Which information regarding the use of methadone is important for the nurse to include?

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 caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

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 caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?