A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?

"I don't like it when you address me with that tone of voice."

"I know you can, but are you going to read it or not?"

"Fine. Here is the schedule, and I will expect you to be on time to your therapies.

"We do this every day. Why are you so angry with me this morning?"

Answer and Explanation

The Correct Answer is A

This response addresses the client's disrespectful tone and sets a boundary regarding acceptable communication. It promotes respect and professionalism in the nurse-client relationship while addressing the immediate behavior.

B. It maintains a neutral tone and encourages cooperation without escalating the conflict. However, it may come across as slightly confrontational and could potentially provoke further resistance from the client.

C. This response accommodates the client's request to have the schedule provided without further interaction. However, it may reinforce the client's dismissive and disrespectful behavior by complying with their demands without addressing the underlying communication issue.

D. It encourages the client to reflect on their feelings and provides an opportunity for open communication about any issues or concerns they may have. However, it may not be the most effective response in the moment as it could potentially escalate the conflict or lead to further defensiveness from the client.

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Correct Answer is A

Explanation

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

A. Tell the client ways to avoid making their partner angry to prevent intimate partner violence. B. Provide the client with strategies for interacting with others in social situations. C. The nurse instructs the client on ways to behave to prevent making their partner angry D. Provide the client with information on resources in the community to support victims of violence. E. Using a moderate amount of eye contact

Correct Answer is D

Explanation

Victims of intimate partner violence require access to resources and support services to help them navigate their situation and make informed decisions about their safety and well-being.
A. Blaming the victim for the violent behavior of their partner is not only ineffective but also unethical.
B. While providing strategies for interacting with others in social situations may be helpful for general social skills development, it is not directly relevant to addressing the immediate needs of victims of intimate partner violence.
C. Instructing the client on ways to behave to prevent making their partner angry is not appropriate. It implies that the victim is responsible for the abusive behavior of their partner, which is not the case.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?

Correct Answer is D

Explanation

A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease?

A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident?

A community health nurse is reflecting on unconscious feelings they may have toward some of the clients they care for. The nurse should identify this as which of the following concepts of cultural competence?

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a culture different than the nurse. Which of the following statements should the nurse make?

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?