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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.

Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.

Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.

Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.

A. Administer an antianxiolytic medication. B. Insert fecal management tube. C. Insert peripheral intravenous catheter. D. Crush pills and place in applesauce.

Correct Answer is C

Explanation

Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.

Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.

Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.

Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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