The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?
Ask in a non-threatening manner why the client cut own abdomen.
Provide detailed thorough explanations when cleansing the wound.
Request another staff member to assist with the dressing change.
Perform the dressing change in a non-judgmental manner.
The Correct Answer is D
Choice A rationale: Asking in a non-threatening manner why the client cut their own abdomen is an appropriate therapeutic communication technique but may not be the priority during a dressing change. Safety and hygiene are essential.
Choice B rationale: Providing detailed thorough explanations when cleansing the wound is valuable, but the nurse should prioritize the physical care and safety aspects of the dressing change.
Choice C rationale: Requesting another staff member to assist with the dressing change may be appropriate for some clients, but it may not be necessary for every situation. The nurse should be capable of performing the dressing change safely. Choice D rationale: Performing the dressing change in a non-judgmental manner is crucial. The nurse should focus on providing care in a sensitive and non-critical way to establish trust and ensure the client's physical well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Changes in thought patterns related to problem-solving demonstrate the effectiveness of cognitive-behavioral techniques. Shifting from hopelessness to active problem-solving reflects positive progress.
Choice B rationale: Describing how the family can resolve problems may involve other therapeutic modalities, but it is not specific to evaluating the effectiveness of cognitive behavioral techniques.
Choice C rationale: Relating insight into problematic relationships is a broad goal and may not specifically measure the impact of cognitive-behavioral techniques. Choice D rationale: Demonstrating a healthy relationship with the husband is an important goal but is not directly related to the evaluation of cognitive-behavioral techniques.
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
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