The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?
Ask in a non-threatening manner why the client cut own abdomen.
Provide detailed thorough explanations when cleansing the wound.
Request another staff member to assist with the dressing change.
Perform the dressing change in a non-judgmental manner.
The Correct Answer is D
Choice A rationale: Asking in a non-threatening manner why the client cut their own abdomen is an appropriate therapeutic communication technique but may not be the priority during a dressing change. Safety and hygiene are essential.
Choice B rationale: Providing detailed thorough explanations when cleansing the wound is valuable, but the nurse should prioritize the physical care and safety aspects of the dressing change.
Choice C rationale: Requesting another staff member to assist with the dressing change may be appropriate for some clients, but it may not be necessary for every situation. The nurse should be capable of performing the dressing change safely. Choice D rationale: Performing the dressing change in a non-judgmental manner is crucial. The nurse should focus on providing care in a sensitive and non-critical way to establish trust and ensure the client's physical well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Self-control is not the primary issue identified in this scenario. The client's self-blame may be related to other factors.
Choice B rationale: Self-actualization is not the primary issue in this scenario. The client is dealing with feelings of self-blame and potential guilt.
Choice C rationale: Self-esteem is the most relevant issue in this scenario. The client expresses feelings of self-blame, indicating a potential impact on self-esteem. Addressing self-esteem is crucial for the client's emotional well-being.
Choice D rationale: Self-absorption is not the primary issue in this scenario. The client's focus on self-blame and guilt is related to self-esteem concerns.
Correct Answer is C
Explanation
Choice A rationale: Fear of large dogs may or may not be related to schizophrenia; other information is needed to determine its significance.
Choice B rationale: Decreased attention to detail is a symptom that may be observed in schizophrenia, but it is not the primary behavior to notify the healthcare provider.
Choice C rationale: Social withdrawal is a concerning behavior in schizophrenia that may indicate worsening symptoms and should be reported to the healthcare provider.
Choice D rationale: Changes in appetite are important to monitor but may not be the primary indicator of a worsening condition in schizophrenia.
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