Nokea
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
- A. Assign different staff members to care for the client each day
- B. Assign the client's stated preferred nurse to care for the client
- C. Reassure the client that all staff members are competent in their jobs
- D. Reinforce unit guidelines and appropriate boundaries with the client
Correct Answer: D
Rationale: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
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The nurse observes a certified nursing assistant (CNA) moving a client up in bed. Which action by the nursing assistant indicates a need for more instruction in how to move a client?
- A. Using a pull sheet
- B. Asking another nursing assistant to help
- C. Lowering the head of the bed
- D. Pulling the client by the shoulders
Correct Answer: D
Rationale: Pulling by the shoulders risks injury to the client's skin and joints. Using a pull sheet, getting help, and lowering the bed are correct techniques to ensure safety.
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. No one is in your room. Let's get you more medicine.'
- B. I do not see anyone, but you seem to be very frightened.'
- C. No one can hurt you here.'
- D. Just tell the person to go away.'
Correct Answer: B
Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.
The LPN/LVN is providing home care to an elderly widow who has senile dementia. The woman tells the nurse that her daughter hits her and tells her to shut up. The nurse notes one ecchymotic area on the client's right forearm. The daughter seems attentive to the woman when the nurse is present. What action should the nurse take?
- A. Immediately call the police
- B. Ask the daughter why she abuses her mother
- C. Ask the physician to order long bone x-rays
- D. Report the woman's remarks and the nurse's findings to the nursing supervisor
Correct Answer: D
Rationale: Reporting suspected abuse to the supervisor initiates investigation and protection, the appropriate action for potential elder abuse.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
The nurse is reinforcing teaching for a client with bipolar disorder who has a new prescription for lithium. Which of the following statements by the client would require follow-up?
- A. I should drink at least 2 to 3 L of fluid daily.'
- B. I can take over-the-counter ibuprofen for pain relief.'
- C. I will maintain a consistent dietary intake of sodium.'
- D. I should have my medication levels checked periodically.'
Correct Answer: B
Rationale: Ibuprofen (B) can increase lithium toxicity, requiring follow-up. Adequate fluid intake (A), consistent sodium (C), and periodic level checks (D) are correct.