A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

"I might file a lawsuit because of how my surgery went."

"Please don't tell my doctor, but I am taking my partner's oxycodone."

"Please don't get me out of bed this morning, It hurts too much."

"I don't want to take my medicine. It makes me sick to my stomach.”

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: "Please don't tell my doctor, but I am taking my partner's oxycodone."

Choice B rationale:

This statement presents an ethical dilemma as it reveals the client's engagement in potentially harmful and illegal behavior – taking a controlled substance prescribed for someone else. The nurse must balance the duty to respect the client's confidentiality with the responsibility to address potential harm to the client and others involved.

Choice A rationale:

"I might file a lawsuit because of how my surgery went" does not present an ethical dilemma, but rather a legal concern. While the nurse should listen to the client's complaints and provide appropriate support, this statement is more related to the client's dissatisfaction with their medical care.

Choice C rationale:

"Please don't get me out of bed this morning, It hurts too much" reflects a client's pain management request. While pain management is important, this statement doesn't raise an ethical dilemma on its own. It's within the scope of care to address pain and comfort concerns.

Choice D rationale:

"I don't want to take my medicine. It makes me sick to my stomach" highlights a client's concern about medication side effects. While addressing medication concerns is essential, this statement doesn't inherently pose an ethical dilemma.

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Correct Answer is D

Explanation

The correct answer is choice d. Actual loss.

Choice A rationale: Complicated grief refers to an intense and prolonged period of mourning that interferes with daily life. It is not typically associated with the immediate postoperative period following a mastectomy.

Choice B rationale: Maturational loss is related to the normal life transitions and developmental changes, such as children leaving home or retirement. It does not apply to the loss experienced after a mastectomy.

Choice C rationale: Disenfranchised grief occurs when a person’s grief is not socially recognized or supported, such as the loss of a pet or an ex-spouse. While the grief after a mastectomy can be profound, it is generally acknowledged and supported by healthcare providers and society.

Choice D rationale: Actual loss refers to the tangible loss of a person, object, or body part. In this case, the client is experiencing the loss of a breast, which is a significant and visible change to their body. This type of loss can deeply affect a person’s self-image and emotional well-being.

A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible.

Correct Answer is D

Explanation

The correct answer is: d. Remove the staple from the skin after both sides are visible.

Explanation: This statement is correct because the staple should be removed only when both sides are visible, ensuring that it has been fully lifted away from the skin. This helps minimize tissue damage and pain while preventing infection.

Choice A Rationale: Lifting the staple remover when squeezing the handle could potentially disrupt the proper angle required for effective staple removal. Staples are designed to be removed in a specific manner to minimize tissue trauma and discomfort to the patient. If the staple remover is lifted while squeezing the handle, it may cause uneven pressure on the staple legs, leading to improper removal. This could result in tissue damage, increased pain for the patient, and potentially leave parts of the staple embedded in the skin, increasing the risk of infection or delayed healing.

Choice B Rationale: Avoiding completely closing the handle after squeezing may not provide sufficient force to properly remove the staple from the skin. Staples are designed to be squeezed closed completely to ensure that they are securely grasped and removed from the incision site. Failing to fully close the handle after squeezing may result in inadequate removal of the staple, leaving parts of it behind in the skin. This can increase the risk of infection, tissue irritation, and delayed wound healing. Additionally, incomplete closure of the handle may lead to discomfort for the patient as the staple removal process may be prolonged or require additional attempts.

Choice C Rationale: Expecting the staples to bend at each outer side during removal is incorrect. Staples are designed to bend in the middle when properly removed from the skin. If the outer sides of the staple were expected to bend, it may indicate improper technique or the use of a faulty staple remover. Staples are intended to be removed smoothly without excessive bending or twisting to minimize trauma to the surrounding tissue and reduce the risk of complications such as infection or delayed wound healing. Anticipating bending at the outer sides could lead to unnecessary manipulation of the staple and increase the likelihood of tissue damage or incomplete removal.

Choice D (Correct Answer) Rationale: Removing the staple from the skin only after both sides are visible is the appropriate technique to ensure proper removal without causing unnecessary trauma or discomfort to the patient. When both sides of the staple are visible, it indicates that the staple has been adequately lifted away from the skin, reducing the risk of tissue damage or incomplete removal. This technique allows for a smooth and controlled extraction of the staple, minimizing pain and promoting optimal wound healing. By waiting until both sides are visible, the nurse can confirm that the staple has been fully disengaged from the tissue, reducing the likelihood of complications such as infection or skin irritation.

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A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Correct Answer is D

Explanation

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

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