Answer to Question 1
Answer: A
Priorities of care for a client with a personality disorder include safety, managing crisis, setting limits, and improving socialization. Because of the nature of the disorder, it may be difficult for a therapeutic nurse-client relationship to be formed, so the nurse should not focus on this. The nurse should not confront the client by asking what purpose is served by disrupting others. Placing the client in a jacket restraint is not indicated in response to this behavior. The best intervention would be for the nurse to remove the disruptive client from the room and address the behavior privately.
Answer to Question 2
Answer: C, E
The nurse should explain that the medal can be safety pinned to the client's gown. This approach would ensure compliance with the client's religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medal is being worn by the client. The nurse should not keep the medal on the client but remove it after anesthesia is provided. The nurse should not tell the client that the medal will be lost if worn or confront the client by asking if the medal is going to ensure successful surgery.
A physician is performing a colonoscopy on a client and viewing the internal structures of the colon
Intervention Model-Response to Client Misconduct
Stretch quadriceps, pushing the heel to the buttocks.
Testing the Achilles tendon reflex with client in a supine position
Position the client
Client positioned and draped