A nurse is assisting a client who is 4 hr postoperative to get out of bed.
The client states, “Do not touch me! I can get up by myself.” Which of the following responses should the nurse make?
“I think you need some pain medication before getting out of bed.”.
“We can talk about this after you have gotten out of bed.”.
“Why don’t you want to be touched?”.
“I will be next to you and will help if you need me to.”.
The Correct Answer is D
The correct answer is choice D. The nurse should respect the client’s autonomy and offer assistance if needed.
The nurse should also assess the client’s pain level and provide adequate pain relief before helping the client get out of bed.
Choice A is wrong because it implies that the client is in pain and needs medication, which may not be true.
The nurse should ask the client about their pain level and offer medication if appropriate.
Choice B is wrong because it dismisses the client’s feelings and does not address the underlying issue of why the client does not want to be touched.
Choice C is wrong because it may make the client feel defensive or interrogated.
The nurse should use open-ended questions and active listening to explore the client’s concerns and fears.
According to web sources, postoperative care involves monitoring and managing the client’s vital signs, pain, wound healing, fluid and electrolyte balance, bowel and bladder function, mobility, and psychological status.
The nurse should also educate the client about self-care, wound care, activity restrictions, medication use, signs of complications, and follow-up appointments.
The nurse should also provide emotional support and reassurance to the client and their family.
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Related Questions
Correct Answer is A
Explanation
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.
The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.
The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.
The client should keep a slight bend in the elbows when walking with crutches
Correct Answer is A
Explanation
The correct answer is choice A. Use a communication board to interact with the client.
A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.
This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.
Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.
Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.
It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.
Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.
It uses facial expressions to rate the severity of pain in children from 0-103.
It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.
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