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 thorough explanations when cleansing wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask in a non-threatening manner why the client cut own abdomen.
- D. Request another staff member assist with the dressing change.
Correct Answer: B
Rationale: The correct answer is B: Perform the dressing change in a non-judgmental manner. When caring for a client with borderline personality disorder who has self-inflicted injuries, it is crucial to approach the situation with empathy and without passing judgment. This approach helps build trust, maintains the therapeutic relationship, and encourages open communication. Providing detailed explanations (choice A) may overwhelm the client. Asking about the self-inflicted behavior (choice C) in a non-threatening manner can be appropriate but should not be the primary focus during the dressing change. Requesting another staff member's assistance (choice D) may not be necessary if the RN can handle the situation effectively.
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A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This is the priority intervention because the client is difficult to arouse, indicating potential risk for airway compromise and aspiration due to the head injury and elevated BAL. Placing the client in a side-lying position with the head of the bed elevated helps prevent aspiration and promotes optimal airway management. Administering disulfiram (choice B) is not indicated as the priority intervention in this acute situation. Giving lorazepam (choice C) for signs of withdrawal may further depress the client's level of consciousness and is not the priority at this time. Providing thiamine and folate supplements (choice D) is important for alcohol-related deficiencies but does not address the immediate risk of airway compromise.
Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don’t bite.
Correct Answer: A
Rationale: The correct answer is A because it clearly communicates the behavior that is unacceptable (hitting when angry) and sets a clear boundary. It addresses the specific behavior and its consequences without being vague or ambiguous. Choice B lacks specificity, choice C is a command without explaining the reason for the request, and choice D uses shaming language which is not effective in setting limits. Choices E, F, and G are irrelevant as they are not provided. Overall, choice A demonstrates a well-structured attempt at limit setting by being clear, specific, and focusing on the behavior that needs to change.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: The correct answer is C: Avoid recognizing the behavior. Echolalia is the repetition of words or phrases spoken by others, common in schizophrenia. By not reinforcing or acknowledging the behavior, the client may eventually stop. Isolating the client (Choice A) may lead to feelings of rejection. Administering a sedative (Choice B) may not address the underlying behavior. Escorting the client to his room (Choice D) does not address the echolalia directly.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Provide education on methods to enhance sleep.
- B. Teach the client to develop a plan for daily structured activities.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Encourage the client to exercise.
Correct Answer: B
Rationale: The correct answer is B: Teach the client to develop a plan for daily structured activities. This intervention is most effective because it addresses the symptoms of psychomotor retardation, hypersomnia, and lack of motivation commonly seen in major depressive disorder. Structured activities can help the client regain a sense of routine, purpose, and accomplishment, which can improve mood and motivation. Providing education on sleep methods (A) may help with hypersomnia but may not address overall functioning. Developing a list of pleasurable activities (C) can be beneficial, but structured activities are more likely to improve functioning. Encouraging exercise (D) can be helpful but may be challenging for someone with psychomotor retardation.
Which nursing statement is an example of reflection?
- A. I think this feeling will pass.
- B. So you are saying that life has no meaning.
- C. I’m not sure I understand what you mean.
- D. You look sad.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates reflective listening by paraphrasing and summarizing the patient's statement. This shows active listening and understanding of the patient's perspective. Choice A is about personal feelings, not reflecting the patient's emotions. Choice C is a statement of uncertainty, not reflective listening. Choice D is an observation, not reflection.