A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
"Aren't you interested in learning how to perform this test?"
"Let's talk about what forethinking."
"I'll discuss this with your partner instead."
"Is this something you think you can do?"
The Correct Answer is B
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A Reason :
Increased peripheral circulation is incorrect. As people age, changes in the cardiovascular system can occur, but increased peripheral circulation isn't a common physiological change. In fact, aging might lead to reduced elasticity in blood vessels, potentially resulting in decreased circulation to some areas.
Choice B Reason:
Increased saliva production is incorrect: Saliva production doesn't usually increase with age. Instead, certain medications, medical conditions, or treatments might impact saliva production. Aging itself doesn't commonly cause an increase in saliva production; in fact, it can decrease due to changes in salivary glands.
Choice C Reason:
Increased constipation is correct. As individuals age, there can be changes in gastrointestinal motility and muscle tone, which can contribute to an increased likelihood of constipation.
Choice D Reason:
Decreased muscle mass is correct. Aging often leads to a natural decline in muscle mass and strength, known as sarcopenia, which can affect mobility and overall physical function.
Choice E Reason:
Decreased cough reflex is correct. With aging, the cough reflex might become less sensitive or effective, which can impact the ability to clear the airways efficiently.
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
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