In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

Controlled anger

Stable and satisfactory relationships

Little tolerance for being alone

Predictability

Answer and Explanation

The Correct Answer is C

C. Individuals with BPD often experience intense fears of abandonment and may go to great lengths to avoid being alone. They may also have difficulties being alone due to chronic feelings of emptiness and the need for others to help manage emotions. This characteristic is consistent with the known symptoms of BPD, which include efforts to avoid real or perceived abandonment and a pattern of intense and unstable relationships.
A. Individuals with borderline personality disorder (BPD) often struggle with regulating their emotions, including anger. While they may experience intense emotions such as anger, they typically have difficulty controlling or expressing it in a healthy and adaptive manner.
B. Stable and satisfactory relationships: Stability in relationships is often a challenge for individuals with BPD. They may experience intense and unstable interpersonal relationships characterized by idealization and devaluation of others.
D. Predictability is generally lacking in individuals with BPD due to their emotional instability, impulsivity, and difficulty regulating their behaviors and responses to situations.

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Correct Answer is C

Explanation

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

A. Assess breath sounds B. Monitor serum protein levels C. Assess peripheral pulses D. Monitor daily weights

Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

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In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Correct Answer is D

Explanation

A client has been taking oxycodone for pain. The client has returned three times for refills of the prescription. In addition to slurred speech, which assessment leads the nurse to suspect opioid Intoxication?

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