A nurse is caring for an adolescent client who is scheduled for surgery. Which of the following actions should the nurse take to prepare the child based on their developmental stage?
Discuss how the procedure might affect the client's appearance.
Avoid involving the client in decisions regarding treatment.
Emphasize that the procedure is not a punishment.
Keep equipment out of the client's sight.
The Correct Answer is A
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Decrease daily oral fluid intake. Rationale: This choice is not appropriate for a client experiencing a vaso-occlusive crisis in sickle cell anemia. In this crisis, there is a risk of dehydration due to increased fluid loss, and decreasing oral fluid intake would exacerbate this issue. Adequate hydration is important to prevent further sickling of red blood cells and maintain organ perfusion.
Choice B rationale:
Maintain bed rest to prevent hypoxemia. Rationale: This is the correct choice. During a vaso-occlusive crisis in sickle cell anemia, blood flow to certain tissues is restricted, leading to tissue hypoxia and pain. Bed rest is recommended to reduce metabolic demands and oxygen consumption, helping to prevent further tissue damage and improve oxygenation. It also reduces the risk of complications such as thrombosis and respiratory compromise.
Choice C rationale:
Apply cold compresses to painful joints. Rationale: Applying cold compresses is not a recommended intervention for vaso-occlusive crisis in sickle cell anemia. Cold can exacerbate vasoconstriction and further compromise blood flow to the affected tissues. Warm compresses or warm baths might be more appropriate to promote vasodilation and alleviate pain.
Choice D rationale:
Administer meperidine to eliminate a fever. Rationale: Administering meperidine solely to eliminate a fever is not the primary focus of care for a vaso-occlusive crisis. The priority is to manage pain and improve tissue perfusion. Meperidine is an opioid analgesic that can be used to manage severe pain associated with sickle cell crises, but it should be given with caution due to the risk of respiratory depression and the potential for addiction.
Correct Answer is D
Explanation
Choice A rationale:
Edema. Edema, the accumulation of fluid in the tissues, is not the primary indicator of compartment syndrome. While edema can occur due to various reasons, it's not specific to compartment syndrome. Compartment syndrome primarily involves increased pressure within a closed space (muscle compartment), which can compromise blood circulation and nerve function.
Choice B rationale:
Mottling. Mottling refers to a patchy, bluish discoloration of the skin that occurs due to poor blood circulation and is often seen in critically ill patients. While it might indicate circulatory issues, it's not a direct sign of compartment syndrome. Compartment syndrome is more closely associated with symptoms such as severe pain, numbness, and decreased or absent pulses.
Choice C rationale:
Urticaria. Urticaria, also known as hives, is a skin rash characterized by raised, itchy, and red or white welts. It is typically caused by an allergic reaction or other factors such as medications. Urticaria is unrelated to compartment syndrome, which involves the compression of nerves and blood vessels within a closed anatomical compartment, leading to ischemia and potential tissue damage.
Choice D rationale:
Pulselessness. Pulselessness is a critical sign that the nurse should monitor when conducting a circulatory check for compartment syndrome. Compartment syndrome occurs when there is increased pressure within a confined space (muscle compartment), leading to compromised blood flow and oxygen delivery to the tissues. The lack of a palpable pulse in the affected area suggests that blood flow is severely compromised. This is a late sign of compartment syndrome and requires immediate intervention to prevent tissue necrosis and long-term complications.
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