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. Conduct Disorder is characterized by a repetitive and persistent pattern of behavior that violates the rights of others or major age-appropriate societal norms or rules. It often includes aggressive behavior towards people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.
B. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social interaction and communication, as well as restricted and repetitive patterns of behavior, interests, or activities.
C. Oppositional behavior is present in ODD but the severity and nature of the behaviors described in the scenario (prostitution, running away, and abuse towards parents) are more consistent with Conduct Disorder rather than ODD.
D. Childhood depression, also known as pediatric depressive disorder, involves persistent feelings of sadness, hopelessness, or irritability that interfere with daily functioning.

A. Assess for past history of suicide attempts. B. Determine whether the client has a specific plan to commit suicide. C. Identify coping mechanisms. D. Notify all members of the treatment team and place the client on suicide precautions.

Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

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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

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

Correct Answer is A

Explanation

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

Correct Answer is D

Explanation

A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?

A client is admitted to a Chemical Addictions Unit to stop using alcohol and to learn about sobriety. The client asks the nurse what medication the doctor has prescribed for possible alcohol withdrawal. The nurse explains that the physician prescribed:

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

An 11-year-old, who is diagnosed with oppositional defiant disorder, becomes angry and disruptive over the rules of the day treatment program. The nurse should de-escalate the situation by:

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. The nurse would recommend that the victim bring:

A woman in a severely abusive relationship is hospitalized with severe injuries and head trauma. Her husband sends flowers to the unit and a card begging for forgiveness. The nurse recognizes this to be which phase in an abusive relationship?

When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for: