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 B
Explanation
Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.
Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.
Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.
Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale: Disrupted sleep is a common symptom of postpartum depression, and clients may experience difficulty falling asleep or staying asleep.
Choice B rationale: Grandiosity is more indicative of bipolar disorder (mania) rather than postpartum depression.
Choice C rationale: Poor concentration is a common cognitive symptom associated with postpartum depression.
Choice D rationale: Compulsive behavior is not typically associated with postpartum depression.
Choice E rationale: Sadness is a hallmark symptom of depression, including postpartum depression.
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