A nurse is caring for a client who is near the end of life and is on complete bed rest.
The client states that he needs to have a bowel movement and the nurse offers a bedpan.
The client states, "I've always used the bathroom." Which of the following responses should the nurse make?
"Tell me what concerns you have about using a bedpan."
"Make sure to use nearby furniture to support yourself when walking to the bathroom."
"You have to use the bedpan for your own safety."
"I will have the physical therapist ambulate you to the bathroom." .
The Correct Answer is A
Choice A rationale:
The nurse should prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.
Choice B rationale:
This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.
Choice C rationale:
This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.
Choice D rationale:
Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.
Choice B rationale:
The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.
Choice C rationale:
The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.
Choice D rationale:
The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.
Correct Answer is A
Explanation
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
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