Nokea
The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?
- A. Provide detailed explanations during wound cleansing.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask the client non-threateningly why they cut their abdomen.
- D. Request assistance from another staff member for the dressing change.
Correct Answer: B
Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.
You may also like to solve these questions
A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct Answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?
- A. That the client may act on suicidal thoughts.
- B. That the client may engage in impulsive behavior.
- C. That the client may be experiencing the side effects of the medication.
- D. That the client may be at risk for developing serotonin syndrome.
Correct Answer: A
Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.
A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Intellectualization
Correct Answer: A
Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?
- A. It may take 3 to 4 weeks to achieve therapeutic effects.
- B. Keep your dietary salt intake consistent.
- C. Avoid eating aged cheese and chicken liver.
- D. Eat foods high in fiber such as whole grain breads.
Correct Answer: B
Rationale: The correct answer is B: 'Keep your dietary salt intake consistent.' Consistent salt intake is crucial when taking lithium carbonate to avoid lithium toxicity or ineffectiveness due to its renal excretion mechanism. Option A is incorrect because it focuses on the time to achieve therapeutic effects, which is important but not as critical as maintaining consistent salt intake. Option C is incorrect as it mentions avoiding aged cheese and chicken liver, which is more relevant for individuals taking MAOIs. Option D is incorrect as it suggests eating high-fiber foods, which is not directly related to lithium carbonate therapy.
A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?
- A. I don't hear any voices. They must be in your head.
- B. What are the voices telling you to do?
- C. You need to ignore the voices and focus on reality.
- D. I know the voices are real to you, but I don't hear them.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.