The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Providing the patient with a pillow to brace the incision

Instructing the patient to perform deep coughing every 30 minutes

Having the patient sit up and lean forward

Giving pain medication prior to coughing

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.

Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.

Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.

Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.

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Correct Answer is A

Explanation

Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.

Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.

Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.

Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.

A. The client's unconscious need to manipulate others B. The client's delusion that cleaning is necessary C. The client's wish to decrease the time available for interaction with others D. The client's attempt to decrease anxiety

Correct Answer is D

Explanation

Choice A reason: OCD is not characterized by an unconscious need to manipulate others but by anxiety-driven compulsions.

Choice B reason: While clients with OCD may feel a need to clean due to contamination fears, it is not a delusion but rather an obsession that drives the compulsion.

Choice C reason: The repetitive cleaning is not typically a conscious choice to decrease social interaction but a compulsion to alleviate anxiety.

Choice D reason: Repetitive behaviors in OCD, such as cleaning, are attempts to decrease the anxiety caused by obsessive thoughts.

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The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and observes that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

Correct Answer is D

Explanation

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Debridement is:

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