A nurse is assisting a client who is 4 hr postoperative with getting 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?
"Why don't you want to be touched?"
"Would you like some pain medication before getting out of bed?"
"I will stand next to you and help if you need me to."
"We can talk about this after you have gotten out of bed."
The Correct Answer is C
A. "Why don't you want to be touched?": Asking "Why" can make a client feel defensive and is considered non-therapeutic communication.
B. "Would you like some pain medication before getting out of bed?": This ignores the client's immediate assertion of independence and safety risk.
C. "I will stand next to you and help if you need me to.":. This response respects the client's autonomy while ensuring safety by maintaining proximity in case the client becomes unsteady.
D. "We can talk about this after you have gotten out of bed.": This dismisses the client's immediate concern and the potential risk of a fall.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "He appears anxious about the transfer.": This is a subjective observation. While helpful, it is not the most critical clinical data point.
B. "He is voiding adequately.": This is vague. A transfer report should include specific data (e.g., "Voided 400 mL of clear yellow urine this shift").
C. "He is allergic to sulfa.": Safety information, particularly allergies, is the most critical information to communicate to the receiving nurse to prevent a life-threatening medication error.
D. "His partner has been visiting.": This is social information and, while helpful for holistic care, is not a priority for a clinical transfer report.
Correct Answer is A
Explanation
A. Brittle hair: Protein-calorie malnutrition often leads to hair that is dull, dry, and brittle, and may eventually fall out (alopecia) due to the lack of nutrients required for hair follicle health.
B. Yellow conjunctivae: This is a sign of jaundice (icterus), usually indicating liver dysfunction or hemolysis, rather than general malnutrition.
C. Clubbing of the fingernails: This is typically a sign of chronic hypoxia (low oxygen levels) associated with cardiac or pulmonary disease, not specifically malnutrition.
D. Bradycardia: While severe starvation can slow the heart rate, tachycardia (a fast heart rate) is a more common finding in the early stages of malnutrition or dehydration.
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