The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

denial.

separation-individuation.

splitting.

reaction formation.

Answer and Explanation

The Correct Answer is C

C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.

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Correct Answer is A

Explanation

A. Lithium carbonate is a medication commonly used to treat bipolar disorder. Symptoms of lithium toxicity can include nausea, vomiting, diarrhea, muscle weakness, tremors, and flu-like symptoms. If a client is experiencing these symptoms after taking lithium carbonate, it could indicate lithium toxicity
B. Lithium is a mood stabilizer, and tolerance, in the sense of needing increasing doses to achieve the same effect, is not commonly observed.
C. Suddenly stopping lithium carbonate can lead to withdrawal symptoms, but the symptoms described— nausea, diarrhea, muscle weakness, and tremors—are more indicative of toxicity rather than withdrawal.
D. Tyramine is a compound found in certain foods and beverages, and interactions between tyramine-rich foods and certain medications, such as monoamine oxidase inhibitors (MAOIs), can lead to hypertensive crises. However, lithium carbonate is not known to have interactions with tyramine-rich foods.

A. call for emergency assistance from other staff. B. take him to a room with toys to act out feelings. C. tell the boy's mother to take him home immediately. D. direct him to stop, then confront the other child.

Correct Answer is B

Explanation

B. Providing a safe and supportive environment for the child to express and manage their emotions is important. Taking the child to a room with toys allows them to engage in play and express their feelings in a constructive manner.
A. Emergency assistance from other staff would typically be reserved for situations posing immediate danger to the child or others, which may not be the case here.
C. Sending the child home immediately could be seen as a punitive measure and may not contribute to the child's understanding of the behavior's impact.
D. Directing the child to stop the behavior and then confronting the other child may escalate the situation and potentially lead to further conflict or aggression.

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The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The best action for the nurse to take with a 5-year-old who runs over to another child in the waiting room and slaps her is to:

Correct Answer is B

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

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