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 A

Explanation

A. Set limits on the amount of time the client talks about delusions.Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client.Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

A. The client talks constantly about the traumatic experience. B. The client is easily startled by loud voices. C. The client reports satisfying personal relationships with family and close friends. D. The client is constantly drowsy and sleeps 11-12 hr daily.

Correct Answer is B

Explanation

A. Constantly talking about the traumatic experience is a symptom of intrusive thoughts and re-experiencing, which is characteristic of PTSD.

B. The client is easily startled by loud voices.
Individuals with PTSD often experience heightened arousal and increased reactivity to stimuli. Being easily startled by loud voices is a common symptom of hypervigilance and increased arousal seen in PTSD.

C. Reporting satisfying personal relationships with family and close friends is less likely in individuals with PTSD. PTSD can negatively impact interpersonal relationships due to symptoms such as emotional numbing, avoidance, and hypervigilance.

D. Constant drowsiness and sleeping 11-12 hours daily are not typical findings in PTSD. Individuals with PTSD may experience sleep disturbances, such as insomnia, nightmares, or hyperarousal-related sleep problems.

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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 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?

Correct Answer is A

Explanation

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is preparing to administer haloperidol 5 mg IM to a client. Available is haloperidol 50 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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