A nurse is assisting with the care of a client.
The nurse is collecting data from the client.
Drag words from the choices below to fill in each blank in the following sentence.
The nurse should identify that
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Rationale for correct choices:
• Emotional lability: The client demonstrates rapid and intense shifts in mood, such as being angry and hostile toward staff, then later praising the nurse excessively. This instability in affect is characteristic of borderline personality disorder (BPD). Emotional lability often leads to interpersonal conflicts and impulsive behaviors, which were observed in aggressive interactions with peers. Recognizing these shifts is essential for guiding therapeutic interventions.
• Fear of abandonment: Clients with BPD frequently experience intense fear of real or perceived abandonment, influencing their relationships and behaviors. The client’s alternating hostility and praise toward the nurse may reflect anxiety over potential rejection or inconsistent attachment. Identifying this fear helps the nurse implement consistent, supportive care while maintaining professional boundaries.
Rationale for incorrect choices:
• Elevated body temperature: There is no evidence of fever or infection in the client. Elevated temperature is not a feature of BPD. It reflects physiological issues unrelated to emotional or behavioral manifestations.
• Tactile hallucinations: The client has not reported or demonstrated perceptual disturbances such as hallucinations. Psychotic symptoms are not part of the core diagnostic features of BPD. Monitoring for hallucinations is unnecessary unless indicated by comorbid conditions.
• Increased heart rate: While heart rate may increase transiently during stress or agitation, it is a physiological response and not a defining characteristic of BPD. Emotional lability and interpersonal fears more accurately reflect the disorder’s manifestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check the client's pedal pulses every hour: Frequent assessment of distal circulation is crucial after a total knee arthroplasty to detect signs of compromised blood flow, such as thromboembolism or compartment syndrome. Monitoring pulses, skin color, and temperature helps identify early complications and prevent tissue damage.
B. Maintain the head of the client's bed in high-Fowler's position: High-Fowler’s position is not recommended post-knee arthroplasty as it can increase strain on the surgical site and reduce venous return from the lower extremities. Keeping the leg elevated and the client in a semi-Fowler’s or supine position is safer.
C. Remove the client's dressing when it becomes saturated: Dressings should only be removed or changed according to the provider’s protocol, typically by sterile technique. Premature removal can increase the risk of infection and disrupt the healing surgical site.
D. Place an abductor wedge under the client's right knee: Abductor wedges are primarily used after hip replacement to maintain hip alignment, not knee arthroplasty. Placing one under the knee could cause discomfort or improper positioning. Proper knee alignment involves elevation and extension support.
Correct Answer is B
Explanation
A. Dorsal recumbent: Lying flat on the back does not optimize airway protection or reduce strain on the surgical site after a thyroidectomy. This position may increase discomfort and risk of edema.
B. Semi Fowler's: Elevating the head of the bed to a semi-Fowler’s position helps reduce neck swelling, promotes airway patency, and decreases tension on the suture line. It also facilitates easier breathing and comfort during the postoperative period.
C. Left lateral: Side-lying positions are not indicated after a thyroidectomy unless the client has specific complications. They do not provide the same benefits for airway management and suture care as semi-Fowler’s.
D. Supine: Lying completely flat can increase neck edema and discomfort post-thyroidectomy. Maintaining a semi-Fowler’s position is preferred to support recovery and airway safety.
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