A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

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

The nurse should identify that
_
and
____
indicate manifestations of borderline personality disorder.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

emotional lability: The client’s sudden and intense shifts in mood, such as calling the nurse "horrible" and then later saying the nurse is "the best," are classic signs of emotional lability. This rapid mood instability is a hallmark feature of borderline personality disorder and reflects difficulties regulating emotions.
increased heart rate: An increased heart rate is a physiological response often linked to anxiety, panic, or substance use but is not a defining characteristic of borderline personality disorder. It does not directly represent a core emotional or relational disturbance seen in this disorder.
elevated body temperature: Elevated body temperature is a physical finding associated with infection, inflammation, or drug reactions. It is not a behavioral or psychological symptom related to borderline personality disorder.
tactile hallucinations: Tactile hallucinations, such as feeling sensations that are not there, are associated with psychotic disorders or substance intoxication rather than borderline personality disorder. They are not characteristic features of this condition.
fear of abandonment: Individuals with borderline personality disorder have a profound fear of abandonment, whether real or perceived. This fear often leads to intense emotional reactions and unstable interpersonal relationships, as seen in the client’s extreme reactions toward the nurse.

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Correct Answer is B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

A. A client who has hearing loss with a friend interpreting B. A client who has not spoken with the provider yet C. A 15-year-old client whose caregiver is not at the bedside. D. A married 16-year-old client accompanied by their spouse

Correct Answer is D

Explanation

A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.

B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.

C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.

D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

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A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

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A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

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

The nurse should identify that
_
and
____
indicate manifestations of borderline personality disorder.