A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?
Did you tell your provider that your family doesn't agree with your decision?
Your family disagrees with your decision?
You are making the same decision I would make.
You should get your family to agree with your decision before signing the consent.
The Correct Answer is B
Choice A reason: Asking if the client informed her provider about family disagreement shifts focus from addressing her emotional needs to a procedural question. It does not facilitate therapeutic communication or explore the client’s feelings about her family’s opposition. This response fails to support the client’s autonomy or address the psychological impact of her decision, making it less effective in this context.
Choice B reason: Restating the client’s concern about family disagreement uses reflective listening, a therapeutic technique that validates her feelings and encourages further discussion. This approach fosters trust, helps the client process her emotions, and supports her autonomy in deciding on the mastectomy, aligning with patient-centered care principles for addressing sensitive decisions.
Choice C reason: Stating that the nurse would make the same decision introduces personal bias, which is inappropriate in therapeutic communication. It shifts focus from the client’s needs to the nurse’s perspective, potentially undermining the client’s autonomy. This response does not address the family’s opposition or support the client’s decision-making process, making it ineffective.
Choice D reason: Suggesting the client needs family agreement before signing consent undermines her autonomy as a competent adult. Informed consent requires only the client’s understanding and agreement, not family approval. This response dismisses the client’s decision-making capacity and fails to address her emotional concerns about family opposition, making it inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.
Correct Answer is D
Explanation
Choice A reason: Absence seizures lack an aura, unlike focal seizures. They involve brief, sudden lapses in consciousness due to generalized cortical discharges, without premonitory symptoms, making this incorrect for educating parents about the characteristics of absence seizures in children.
Choice B reason: Absence seizures last 5-20 seconds, not 30-60 seconds. These brief staring spells are caused by spike-wave discharges on EEG. Prolonged duration suggests other seizure types, making this inaccurate for teaching parents about absence seizure presentation and duration.
Choice C reason: Absence seizures are managed with anticonvulsants like ethosuximide, not surgery. Surgical intervention is for refractory focal seizures, not generalized absence seizures, which respond to medication. This is incorrect for educating parents about treatment options for absence seizures.
Choice D reason: Absence seizures cause a daydreaming appearance, with staring and brief unresponsiveness due to synchronized cortical discharges. This hallmark symptom, lasting seconds, is critical for parents to recognize, aiding identification and management of absence seizures in school settings.
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