A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who had a renal biopsy 3 hr ago and has pink-tinged urine
A client who has a femur fracture and reports numbness of the toes
A client who has cirrhosis and severe pruritus
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
The Correct Answer is B
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.
Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.
Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.
Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.
Correct Answer is B
Explanation
It is important for the nurse to acknowledge the client's fears and show empathy toward them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard. Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated which may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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