A nurse is working with a client with borderline personality disorder. Within the first hour of the shift, the client went from laughing and joking with other clients, to getting angry and shouting at these clients, and then crying in their room because “everyone hates me.” This is an example of what feature of borderline personality disorder?

Impulsivity

Emotional lability

Reaction formation

Splitting

Answer and Explanation

The Correct Answer is B

A: Impulsivity refers to acting on urges without considering consequences, which is a feature of borderline personality disorder but not the best description of the scenario.
B: Emotional lability, or rapid and intense mood swings, accurately describes the client’s behavior in the scenario.
C: Reaction formation involves behaving in a way that is opposite to one’s true feelings, which is not depicted in the scenario.
D: Splitting involves viewing people or situations as all good or all bad, which can be a feature of borderline personality disorder but is not the primary feature shown in the scenario.

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Correct Answer is C

Explanation

A: While muttering to themselves can be observed in children with Autism Spectrum Disorder (ASD), it is not a definitive characteristic. Denying hallucinations is more related to psychotic disorders rather than ASD.

B: Children with ASD typically have difficulties with social interactions and are less likely to freely walk up to strangers and engage in conversation. This behavior is more characteristic of children without ASD.

C: Poor eye contact and lack of verbal response to questions are common observations in children with ASD. These behaviors reflect the social communication deficits that are central to the diagnosis of ASD.

D: Getting into fights with teachers is not a specific characteristic of ASD. While some children with ASD may exhibit challenging behaviors, this is not a defining feature of the disorder.

A. “I’m thirsty, give me a drink of water.” B. “I punched him because he’s rude to us.” C. “I’m going to report you because this is an illegal use of restraints.” D. “If I say I’m sorry, would you let me out of here?”

Correct Answer is A

Explanation

A: This statement requires immediate attention because it indicates a basic need that must be addressed to ensure the patient’s well-being while in restraints.

B: This statement reflects the patient’s justification for their behavior but does not require immediate attention.

C: This statement indicates the patient’s intention to report the use of restraints but does not require immediate attention.

D: This statement reflects the patient’s attempt to negotiate release from restraints but does not indicate an immediate need.

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Naxlex Comprehensive Predictor Exams

A nurse is performing an assessment on a 9-year-old child who had been diagnosed with Autism Spectrum Disorder. Which of the following findings would the nurse expect to observe?

Correct Answer is C

Explanation

A patient was placed in restraints after punching a staff member. Which statement by the patient requires the nurse’s immediate attention?

Correct Answer is A

Explanation

Which client situation requires the nurse to prioritize the implementation of limit setting?

The nurse is developing a plan of care for the client newly diagnosed with anorexia nervosa who is receiving inpatient treatment. According to the client needs, prioritize the outcomes from most urgent to least urgent.

A client diagnosed with a personality disorder states, “You are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 p.m.” This statement would be associated with which personality disorder?

A nurse is working with a client who routinely lies to staff, refuses to comply with unit rules, and shows no remorse for the people they have harmed with their behavior. These behaviors best describe what personality disorder?

A new nurse is working in an adolescent residential program for children with impulse control disorders. Which action would require the charge nurse to immediately follow up with the new nurse? When the new nurse…

Which of the following patients is most likely to become violent?

A nurse is caring for a client who has schizophrenia. The client exclaims, “Aliens came into my room last night and took a sample of my blood!” Which of the following responses should the nurse make?