A nurse is caring for a client who expresses conflicted feelings about undergoing a tubal ligation. Which of the following responses should the nurse make?

"Maybe you should wait to have the procedure."

"This is a common feeling for clients to have before the procedure."

Share more with me about your concerns related to the procedure."

"Why are you concerned about the procedure?"

Answer and Explanation

The Correct Answer is C

A. "Maybe you should wait to have the procedure."

This response may come across as directive and could potentially influence the client's decision. It does not encourage the client to express their feelings or concerns but suggests a specific course of action.

B. "This is a common feeling for clients to have before the procedure."

While it's true that many clients may experience conflicted feelings before undergoing certain procedures, this response is somewhat dismissive. It does not invite the client to explore their specific concerns and may not address the individual nature of the client's feelings.

C. Share more with me about your concerns related to the procedure.

This response encourages the client to express their concerns and provides an opportunity for the nurse to understand the specific issues causing the conflict. It demonstrates empathy and openness, fostering a therapeutic nurse-client relationship. By inviting the client to share more, the nurse can gain insight into the client's emotional and psychological concerns about the tubal ligation.

D. "Why are you concerned about the procedure?"

While this question is an attempt to understand the client's concerns, it may be perceived as too direct or confrontational. The wording might make the client feel defensive or pressured to justify their feelings. The more open-ended phrasing in option C is generally more conducive to therapeutic communication.

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Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

A. Engage the client in a repetitive activity as a distraction. B. Place the client in a seclusion room. C. Apply wrist restraints to the client. D. Administer PRN haloperidol IM to the client

Correct Answer is A

Explanation

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

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A nurse is caring for a client who expresses conflicted feelings about undergoing a tubal ligation. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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