A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Gently suction secretions from the wound bed using a 12-gauge sterile catheter.

Cover the area with saline-soaked sterile dressings.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.

Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.

Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.

Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.

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Correct Answer is D

Explanation

Choice A reason: Euphoria is not typically a defense mechanism; it's a feeling of intense excitement and happiness.

Choice B reason: Depression is a mental health condition, not a defense mechanism.

Choice C reason: Manipulation can be a behavior exhibited by individuals with certain personality disorders, but it is not considered a primary defense mechanism.

Choice D reason: Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person.

A. Make decisions for the patient at the patient's request. B. Avoid situations that the patient may perceive as demeaning. C. Greatly limit social contact to decrease the chance of regressing to prior problematic behavior. D. Avoid discussing the treatment plan to decrease the chance of the patient manipulating the plan. E. Maintain honest, open communication

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Making decisions for the patient can undermine their autonomy and is not therapeutic in treating Paranoid Personality Disorder.

Choice B reason: Avoiding situations that the patient may perceive as demeaning is actually an appropriate intervention, as it helps to build trust and rapport.

Choice C reason: Greatly limiting social contact is not recommended as it can increase feelings of isolation and paranoia.

Choice D reason: Avoiding discussion of the treatment plan is not appropriate; patients should be involved in their care decisions to the greatest extent possible.

Choice E reason: Maintaining honest, open communication is an appropriate and necessary intervention for building a therapeutic relationship with a patient with Paranoid Personality Disorder.

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A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primary mechanism used by people with personality disorders is:

Correct Answer is D

Explanation

Which of the following are NOT appropriate nursing interventions for Paranoid Personality Disorders? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A general goal for a patient with a Personality Disorder is:

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