A nurse is caring for a client who is 3 days postoperative following surgical repair of a hip fracture. Which of the following actions should the nurse take to involve the client in decision making?
Report the healing status of the client's surgical site to the provider.
Assist the client to perform exercises and ambulate on the unit.
Consult the client about options proposed by the physical therapist.
Ask the client to their pain on a scale from 0 to 10 every 12 hr.
The Correct Answer is C
A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.
B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.
C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.
D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "I should expect my periods to resume in 1 month.": This statement suggests a misunderstanding of the procedure. After a vaginal hysterectomy, periods will not resume because the uterus is removed. If a client expresses such expectations, it may indicate a lack of understanding about the procedure's outcomes and risks, meaning informed consent may not have been adequately given.
B) "I will have a large scar on my stomach after this procedure.": A vaginal hysterectomy is typically performed through the vaginal canal, not requiring an abdominal incision. Therefore, this statement reflects a misunderstanding of the procedure's approach, and would indicate that the client has not been fully informed about the surgical method.
C) "I am thankful I am done having children.": This statement indicates that the client has understood one of the key reasons for having a vaginal hysterectomy. The procedure typically results in the inability to conceive children, which is an important consideration for informed consent. It shows the client is aware of the consequences and is making an informed decision.
D) "I will no longer need regular gynecological examination.": This statement reflects a misunderstanding. Even after a hysterectomy, it’s important for clients to continue routine gynecological exams, as they may still need to monitor other aspects of their reproductive health, including the vagina and ovaries (if retained). It indicates that the client may not have been fully informed about post-operative care requirements.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
B. A chest X-ray: The client’s symptoms (cough, blood-tinged sputum, night sweats, fever, and weight loss) are concerning for tuberculosis (TB) or another pulmonary infection. A chest X-ray is a key diagnostic tool to assess for lung abnormalities, including TB infiltrates or cavitations.
D. A Mantoux test: The Mantoux tuberculin skin test (TST) is used to screen for Mycobacterium tuberculosis infection. Given the client’s recent travel to South Africa, a high TB prevalence area, and their symptoms, TB testing is crucial.
Incorrect:
A. A pulmonary function test: This evaluates chronic respiratory conditions like asthma or COPD, but is not a first-line test for an acute cough with systemic symptoms.
C. A nasopharyngeal swab: This is used for diagnosing viral infections like influenza or COVID-19, which are less likely given the client’s blood-tinged sputum and prolonged systemic symptoms.
E. Blood cultures: These are used to detect bacteremia or sepsis, but there is no indication of systemic bacterial infection (e.g., hemodynamic instability, severe leukocytosis).
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