A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

Respect the client's need for social isolation.

Encourage the client's family members to perform the client's ADLS.

Discourage the client from talking about activities he did prior to the amputation.

Determine the client's stage of grief.

Answer and Explanation

The Correct Answer is D

A. Respect the client's need for social isolation:
While it's important to respect the client's need for moments of solitude and privacy, complete social isolation can lead to feelings of loneliness and exacerbate depressive symptoms. Balance is key; the nurse should encourage social interactions and support while respecting the client's need for personal space and alone time.

B. Encourage the client's family members to perform the client's ADLs:
Encouraging the client's family members to take over all activities of daily living (ADLs) can strip the client of their independence and self-efficacy. Instead, the nurse should support the client in actively participating in their self-care activities to the extent they are able. This promotes a sense of control and empowerment during a challenging time.

C. Discourage the client from talking about activities he did prior to the amputation:
Discouraging the client from discussing their life before the amputation can hinder the process of accepting the loss. Allowing the client to talk about their past experiences, activities, and memories can be therapeutic. It helps them process the grief associated with the amputation and allows for a healthy expression of emotions.

D. Determine the client's stage of grief:
Understanding the client's stage of grief is crucial. Grieving is a natural and individual process, and different people progress through stages like denial, anger, bargaining, depression, and acceptance at their own pace. By identifying the client's current stage of grief, the nurse can offer tailored support and interventions, ensuring the client's emotional needs are met effectively.

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Correct Answer is D

Explanation

A. Magnesium hydroxide:
Magnesium hydroxide is an antacid commonly used to relieve indigestion and heartburn. It does not have any known significant interactions with tranylcypromine. MAOIs typically do not interfere with antacids.

B. Ibuprofen:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain and inflammation. It does not have specific interactions with tranylcypromine. However, individuals taking MAOIs should be cautious about using NSAIDs due to the potential risk of bleeding, especially gastrointestinal bleeding. While it's not a direct interaction, it's generally advisable for individuals taking MAOIs to consult their healthcare provider before using NSAIDs.

C. Ranitidine:
Ranitidine is an H2 blocker used to reduce stomach acid production. It does not have any known significant interactions with tranylcypromine. H2 blockers like ranitidine are often used to manage gastrointestinal issues and are generally considered safe when taken with MAOIs.

D. Pseudoephedrine:
Pseudoephedrine is a decongestant commonly found in cold and allergy medications. It can cause a dangerous increase in blood pressure when combined with MAOIs, potentially leading to a hypertensive crisis. Due to this serious interaction, individuals taking MAOIs are strongly advised to avoid medications containing pseudoephedrine.

A. The client follows a strict routine of daily activities. B. The client reports having a substance use disorder. C. The client is a twin D. The client's mother abandoned him as a child. E. The client's father has an impulse control disorder.

Correct Answer is ["B","D","E"]

Explanation

A. The client follows a strict routine of daily activities:
This choice is less likely to be a risk factor for borderline personality disorder. BPD is characterized by impulsivity and difficulties in maintaining stable routines or relationships. Individuals with BPD often struggle with adhering to strict routines due to impulsive behaviors and emotional dysregulation.

B. The client reports having a substance use disorder:
Individuals with borderline personality disorder often struggle with impulse control and emotional regulation. Substance use can be a way for them to cope with intense emotions and mood swings. The presence of a substance use disorder can indicate a higher risk for borderline personality disorder due to these coping mechanisms.

C. The client is a twin:
Being a twin, in itself, is not a direct risk factor for borderline personality disorder. However, if there are genetic or environmental factors contributing to the disorder, both twins might be at risk due to shared genetic material and upbringing. It's essential to consider the specific familial and environmental context when assessing the risk in twins.

D. The client's mother abandoned him as a child:
Early childhood experiences play a significant role in the development of personality disorders, including borderline personality disorder. Abandonment, neglect, or other forms of trauma can disrupt a child's sense of security and trust, leading to difficulties in regulating emotions and forming stable relationships later in life.

E. The client's father has an impulse control disorder:
Growing up in an environment where a parent has an impulse control disorder can create an unstable living situation. Inconsistent parenting and unpredictable behaviors can contribute to emotional instability and difficulties in regulating impulses, which are hallmark features of borderline personality disorder.

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A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

Nursing Test Bank

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Correct Answer is D

Explanation

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Explanation

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