The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Providing the patient with a pillow to brace the incision

Instructing the patient to perform deep coughing every 30 minutes

Having the patient sit up and lean forward

Giving pain medication prior to coughing

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.

Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.

Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.

Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.

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Correct Answer is A

Explanation

Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.

Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.

Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.

Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.

A. Schizotypal B. Narcissistic C. Antisocial D. Borderline

Correct Answer is A

Explanation

Choice A reason: Schizotypal personality disorder is characterized by odd beliefs, eccentric behavior, and difficulty with social relationships, yet individuals can still function in society.

Choice B reason: Narcissistic personality disorder involves a pattern of grandiosity and a need for admiration, not necessarily bizarre behavior.

Choice C reason: Antisocial personality disorder is marked by a disregard for the rights of others, not specifically bizarre behavior.

Choice D reason: Borderline personality disorder includes instability in relationships and self-image, which may not be described as "very bizarre behavior".

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The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

Patients who display very bizarre behavior but who are still functional in society are most likely to have which of the following types of personality disorder?

Correct Answer is A

Explanation

A nurse is assisting with the care of a malnourished patient being prepared for surgery. Which statement by the patient regarding nutrition would indicate adequate teaching?

When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

The nurse is collecting data on a patient with minor chronic venous disease. What findings are anticipated?

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

A primary mechanism used by people with personality disorders is:

The nurse is caring for a patient undergoing surgery with the nursing diagnosis of deficient knowledge related to lack of previous surgical experience. Which nursing intervention is appropriate? (Select all that apply.)

The mental health status examination includes (select all that apply):

Nurses understand that patients who deliberately pretend to be ill are: