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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inserting a straight urinary catheter for a client:
Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.
B. Performing perineal care for a client who has an indwelling urinary catheter.
Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.
C. Showing a client how to use an incentive spirometer:
Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.
D. Increasing oxygen flow for a client who has a nasal cannula:
Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.
Correct Answer is A
Explanation
A. Repositioning the client by log-rolling is a critical intervention after lumbar laminectomy surgery. Log-rolling involves turning the entire body as a unit to prevent twisting or bending at the waist, which can strain the surgical site and potentially cause injury. This method helps protect the spine and maintain alignment during movement.
B. Placing a pillow under the client's back while supine is generally not recommended after a lumbar laminectomy. It may cause hyperextension of the spine, leading to discomfort and potential strain on the surgical site.
C. Removing the back brace when the client is out of bed is not a standard practice without specific orders from the surgeon. Back braces are often prescribed for support and stabilization during movement, especially in the early postoperative period.
D. Maintaining the head of the bed at 90° is not advisable after a lumbar laminectomy. The positioning of the bed should be individualized based on the surgeon's preferences, but typically, keeping the bed flat or in a slightly elevated position is more appropriate to reduce strain on the surgical site.
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