As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

I know you can read it yourself, but will you?"

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

“I expect you to speak to me in a civil tone of voice."

Fine. Here is the schedule. I expect you to be on time for your therapy sessions.

Answer and Explanation

The Correct Answer is C

A. "I know you can read it yourself, but will you?" This response may escalate the situation and may not effectively address the inappropriate tone. It also has the potential to be perceived as confrontational.

B. "We do this every day. Why are you so angry with me this morning?" This response is somewhat confrontational and may not be as effective in setting clear boundaries. It also focuses on the client's emotion without directly addressing the inappropriate tone.

C. “I expect you to speak to me in a civil tone of voice."

Option C sets clear boundaries and communicates the expectation of respectful communication. Addressing the inappropriate tone of voice is important in working with individuals with borderline personality disorder. It reinforces the importance of maintaining a therapeutic and respectful interaction.

D. "Fine. Here is the schedule. I expect you to be on time for your therapy sessions." While this response provides the information, it doesn't address the issue of the client's disrespectful tone. It's important to address the inappropriate behavior while still providing necessary information.

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Correct Answer is C

Explanation

A. Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.

B. Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.

C. Decreasing anxiety to a tolerable level.
In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.

D. Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.

A. Uncontrolled movements around the mouth B. Seizures and tremors C. Nause And vomiting D. Hallucinations and delusions

Correct Answer is A

Explanation

A. Uncontrolled movements around the mouth.
Tardive dyskinesia is a side effect associated with the long-term use of antipsychotic medications, especially first-generation or typical antipsychotics. It is characterized by involuntary, repetitive movements, often involving the face, such as uncontrolled movements around the mouth (e.g., lip smacking, puckering, chewing).

B. Seizures and tremors are not typical adverse effects of tardive dyskinesia. They are more commonly associated with other side effects or conditions.

C. Nausea and vomiting are not typically associated with tardive dyskinesia. These symptoms may be side effects of antipsychotic medications, but they are not characteristic of tardive dyskinesia itself.

D. Hallucinations and delusions are not associated with tardive dyskinesia. Tardive dyskinesia primarily involves involuntary movements and is not related to changes in thought content or perception.

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As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Correct Answer is C

Explanation

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

Correct Answer is A

Explanation

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

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A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?

A nurse is reinforcing teaching with a client who has a prescription for amitriptyline. (Elavil) Which of the following client statement indicates an understanding of the teaching?

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?