A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

"Most people are scared their first time in a health care facility."

"We can discuss what you can expect during your stay."

"You have nothing to worry about. Everything will be fine."

"Why are you feeling scared about being in this facility?

Answer and Explanation

The Correct Answer is B

"Most people are scared their first time in a health care facility":

While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.

"We can discuss what you can expect during your stay":

This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.

"You have nothing to worry about. Everything will be fine":

This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.

"Why are you feeling scared about being in this facility?":

While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.

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Correct Answer is D

Explanation

A. Administer an antiemetic:

Administering an antiemetic might be necessary to relieve nausea and vomiting, but it is not the first action. Before administering medications, it is essential to assess the client's condition and gather information about the underlying cause of the symptoms.

B. Offer pain medication:

Offering pain medication is not the first action. The nurse needs to assess the client's condition, determine the cause of the pain, and gather more information before administering pain relief. Administering pain medication before a thorough assessment can mask important clinical signs and symptoms.

C. Palpate the abdomen:

Palpating the abdomen is an important step in the assessment, but it should follow auscultation of bowel sounds. Palpation can be deferred if there is concern about possible inflammation (as in suspected appendicitis) to avoid causing further irritation.

D. Auscultate bowel sounds:

This is the correct action. Auscultating bowel sounds is the first step in assessing the gastrointestinal (GI) function. The reported symptoms of right lower quadrant pain, nausea, and vomiting could be indicative of various GI issues, such as appendicitis. Assessing bowel sounds helps the nurse gather information about the status of peristalsis and potential obstructions.

A. Ask the family if they wish to assist in washing the client's body. B. Turn overhead lights to a bright setting. C. Leave the client's eyes open until the family views the body. D. Remove the client's dentures for their family to keep.

Correct Answer is A

Explanation

A. Ask the family if they wish to assist in washing the client's body:

This is an appropriate action. Providing an opportunity for the family to participate in postmortem care can be a culturally sensitive and therapeutic approach. It allows the family to be involved in a meaningful way and may contribute to the grieving process.

B. Turn overhead lights to a bright setting:

This is incorrect. The environment for postmortem care should be handled with respect and consideration for the family. Turning the lights to a bright setting may create an uncomfortable or clinical atmosphere. A calm and serene environment is more appropriate for this sensitive task.

C. Leave the client's eyes open until the family views the body:

This is incorrect. It is customary to gently close the deceased person's eyes as part of postmortem care. Leaving the eyes open may be distressing for the family and does not contribute to creating a peaceful appearance.

D. Remove the client's dentures for their family to keep:

This is incorrect. Dentures are typically returned to the family rather than kept by the family. The nurse should handle the removal of any personal items with sensitivity and respect, returning them to the family as appropriate.

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A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?

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