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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. "What happened to you in the past to make you so desperate?" may be seen as judgmental and may not be as helpful in the immediate crisis. It assumes a specific cause for the desperation and might not address the current feelings or circumstances that are contributing to the suicidal thoughts.
B. "What will you accomplish by taking your life?"This question may be perceived as confrontational or dismissive of the client's feelings. It might not provide a clear understanding of the immediate risk or plan.
C. "Why do you feel depressed enough to end your life?" is a direct question that may put pressure on the client and might not be as effective in exploring their thoughts and feelings. It assumes a direct link between depression and suicidal thoughts without allowing for a more nuanced exploration.
D. "How will you carry out your plan?"This question is crucial because it helps assess the seriousness of the client's intent and the immediacy of the risk. Understanding the specifics of the plan can help the nurse evaluate the level of danger and take appropriate actions to ensure the client's safety.
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