A nurse is assisting with the care of a client and is collecting data from the client.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The nurse should identify that
dropdown
and
dropdown
indicate manifestations of borderline personality disorder

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

The nurse should identify that emotional dysregulation and fear of abandonment indicate manifestations of borderline personality disorder. Emotional dysregulation is a hallmark of borderline personality disorder (BPD), characterized by intense and rapidly shifting emotions. Fear of abandonment is a core feature of BPD, leading to anxiety and distress over perceived or anticipated rejection by significant others.

A.   Tactile hallucinations: Tactile hallucinations refer to false perceptions of touch or physical sensations on the skin, which are not typically associated with borderline personality disorder. These hallucinations are more commonly associated with conditions like schizophrenia or substance-induced disorders.
B.   Emotional ability: Emotional dysregulation is a hallmark of borderline personality disorder (BPD). Individuals with BPD often experience intense and rapidly shifting emotions that can be triggered by seemingly minor events. This emotional volatility can lead to difficulties in interpersonal relationships and impulsive behaviors.
C.   Fear of abandonment: Fear of abandonment is a core feature of borderline personality disorder. Individuals with BPD often experience intense anxiety and distress when they perceive or anticipate rejection or abandonment by significant others. This fear can drive their behaviors, including efforts to prevent real or imagined abandonment.
D.   Elevated body temperature: Elevated body temperature is not a characteristic manifestation of borderline personality disorder. Instead, it may be associated with medical conditions such as infections or inflammatory processes.
E.   Increased heart: While emotional distress and anxiety are common in individuals with borderline personality disorder, "increased heart" is not a specific manifestation of the disorder. Anxiety and emotional distress can lead to physiological responses such as increased heart rate, but this is a general response rather than a defining characteristic of BPD.

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Correct Answer is ["A","C","D","F","G","H"]

Explanation

A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

A. The client is assigned to a room with negative airflow. B. The client's meal tray includes ice cream with fresh fruit. C. The client has artificial flowers in the room. D. The client's meal tray contains hard-boiled eggs.

Correct Answer is B

Explanation

A. A room with negative airflow helps prevent the spread of airborne pathogens, which is helpful for immunocompromised clients like those with HIV, but it doesn't directly increase the risk of infection.
B. Correct. Neutropenic clients have reduced immune responses, and consume fresh fruit (which might carry bacteria. can increase the risk of infection.
C. Artificial flowers might be removed due to infection control concerns, but their presence doesn't significantly increase infection risk.
D. Hardboiled eggs are not necessarily a high-risk food for infection in neutropenic clients.

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A nurse is assisting with the care of a client and is collecting data from the client. Exhibits Select words from the choices below to fill in each blank in the following sentence. The nurse should identify that dropdown and dropdown indicate manifestations of borderline personality disorder

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a newly admitted client. Which of the following findings should the nurse report immediately to the provider? Select all that apply.

Correct Answer is ["A","C","D","F","G","H"]

Explanation

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

Correct Answer is B

Explanation

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

A nurse overhears two assistive personnel (AP. in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following Instructions should the nurse include?

A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is assisting with the care of a client and is collecting data from the client.

Exhibits

Select words from the choices below to fill in each blank in the following sentence.

The nurse should identify that
dropdown
and
dropdown
indicate manifestations of borderline personality disorder