A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Gently suction secretions from the wound bed using a 12-gauge sterile catheter.

Cover the area with saline-soaked sterile dressings.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.

Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.

Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.

Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.

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Correct Answer is ["A","B","C"]

Explanation

Choice A reason: One of the primary goals of pharmacotherapy in schizophrenia is to reduce psychotic symptoms to improve the patient's ability to perform daily self-care activities.

Choice B reason: Decreasing psychotic symptoms to help the patient maintain employment is another goal, as it contributes to the patient's independence and quality of life.

Choice C reason: Reducing symptoms to allow for the maintenance of normal social relationships is also a key goal, as social functioning is often impaired in schizophrenia.

Choice D reason: While the ultimate goal may be to cure schizophrenia, currently, pharmacotherapy aims to manage symptoms as there is no cure for the condition.

Choice E reason: Increasing delusional symptoms is not a goal of treatment; the aim is to decrease such symptoms.

A. "You seem to be having some very frightening thoughts." B. "Why do you think you are being lied about and poisoned?" C. "You are mistaken. Nobody is lying about you or trying to poison you." D. "Who is lying about you and trying to poison you?"

Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

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A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are the primary goals of pharmacotherapy for patients diagnosed with schizophrenia? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Effective coping skills are described as:

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

The nurse is collecting data on a patient with minor chronic venous disease. What findings are anticipated?

Ms. T complains of headaches and body pains whenever her husband mentions that the house needs to be cleaned. This has been a recurring problem for more than 6 months. Ms. T probably is suffering from what kind of disorder?

During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

The mental status examination takes place during which part of the nursing process?

The nurse is caring for a patient undergoing surgery with the nursing diagnosis of deficient knowledge related to lack of previous surgical experience. Which nursing intervention is appropriate? (Select all that apply.)