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Questions 176

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Extract:


Question 1 of 5

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?

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.

Question 2 of 5

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.

Correct Answer: A, B, D

Rationale: Date of birth (
A), first and last name (
B), and medical record number (
D) are reliable identifiers. Health care provider (
C) and room number (E) are not specific to the client.

Question 3 of 5

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?

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.

Question 4 of 5

The practical nurse is collaborating with the registered nurse to form a care plan for a client with a possible diagnosis of Guillain-Barré syndrome. The nurse should give priority to which client assessment?

Correct Answer: D

Rationale: Respiratory assessment (
D) is the priority in Guillain-Barré syndrome due to the risk of respiratory muscle paralysis. Reflexes (
B) are relevant but less urgent, and blood pressure (
A) and pupils (
C) are not primary concerns.

Question 5 of 5

Diagnosis-related groups (DRGs) provide data to

Correct Answer: C

Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.

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