A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?
"Why have you decided not to have the procedure?"
"Don't worry. You will adjust to the colostomy quickly."
"It sounds like you have concerns about the procedure."
"Do you think that's the right decision for you and your family?"
The Correct Answer is C
Answer: C
Rationale:
C) "It sounds like you have concerns about the procedure."
This response is therapeutic and encourages the client to express their concerns, allowing the nurse to understand the client's feelings without judgment. It opens up a supportive dialogue where the client can discuss their fears, anxieties, or misconceptions about the colostomy, which can then be addressed appropriately.
A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.
B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.
D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Place the client close to the nurses' station:
While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.
B) Cover the site with a stockinette dressing:
Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.
C) Administer a sedative:
Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.
D) Apply a soft mitten restraint:
This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.
Correct Answer is C
Explanation
A) Restraining a client without a provider's prescription:
This action represents assault and false imprisonment rather than negligence. Assault involves the threat of harm or unwanted touching, while false imprisonment involves the unlawful restraint or restriction of a person's freedom of movement.
B) Threatening to administer a medication a client has refused:
Threatening to administer a medication against a client's wishes may constitute assault or battery, depending on the circumstances, but it does not directly relate to negligence unless the threat results in harm due to the nurse's failure to adhere to the standard of care.
C) Failing to notify the provider after a medication error:
Negligence involves a breach of duty of care resulting in harm to another person. Failing to notify the provider after a medication error represents negligence because it breaches the duty of care owed to the client and may result in harm if appropriate actions are not taken promptly to mitigate the error's effects.
D) Documenting false information in a client's medical record:
Documenting false information in a client's medical record is a form of falsifying documentation and can have serious consequences, including legal and professional repercussions. However, it does not directly relate to negligence unless the false documentation leads to harm or adverse outcomes for the client.
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