A nurse is caring for a client who is scheduled for a bronchoscopy. The client states, "I no longer wish to have this procedure." Which of the following responses should the nurse make?
"Why have you changed your mind about the procedure?"
"You have the right to refuse the procedure."
"Have you had any troubles with swallowing?
"Your doctor wants you to have this procedure."
The Correct Answer is B
Rationale:
A. "Why have you changed your mind about the procedure?": Asking “why” can feel confrontational and may pressure the client to justify their decision rather than respecting their autonomy. It’s better to acknowledge their feelings without judgment.
B. "You have the right to refuse the procedure.": Affirming the client’s right to refuse respects their autonomy and legal rights. It opens the door for further discussion and ensures informed consent is voluntary and ongoing.
C. "Have you had any troubles with swallowing?": This question is unrelated to the client’s decision to refuse the bronchoscopy and does not address their expressed concern or right to refuse.
D. "Your doctor wants you to have this procedure.": Emphasizing the provider’s wishes may pressure the client and undermine their autonomy. The nurse’s role is to support informed decision-making, not to coerce.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.
B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.
C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.
D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.
Correct Answer is B
Explanation
Rationale:
A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.
B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.
C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.
D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.
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