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 A
Explanation
Choice A rationale:
A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.
Choice B rationale:
Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.
Choice C rationale:
Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.
Choice D rationale:
Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.
Correct Answer is B
Explanation
In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:
B) A client who is 1 day postoperative following a vertebroplasty.
Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.
The other options:
A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.
C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.
D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.
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