A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response?

"It will be a change for you, but a normal lifestyle is still possible. What concerns you the most? “

"How has your husband reacted to the news? “

"Don't worry Many patients have had this same surgery and learn to manage very well. “

"You sound like you are in disbelief. Why do you feel this way?"

Answer and Explanation

The Correct Answer is A

A. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?": This response acknowledges the patient's feelings while offering reassurance that life can still be fulfilling after surgery. It also invites the patient to express their concerns, allowing the nurse to address specific worries and provide tailored support.

B. "How has your husband reacted to the news?": While understanding the patient's support system is important, this response does not directly address the patient's expressed feelings of disbelief and may not be the most immediate concern for the patient at this moment.

C. "Don't worry. Many patients have had this same surgery and learn to manage very well.": While meant to offer reassurance, this response may come across as dismissive of the patient's feelings of disbelief and anxiety about the upcoming surgery.

D. "You sound like you are in disbelief. Why do you feel this way?": This response acknowledges the patient's expressed emotion but may come across as confrontational or probing, potentially making the patient feel defensive. It's important to provide support and reassurance while inviting the patient to share their concerns in a non-threatening manner.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. You should advance your weak leg forward to the cane, then move your strong leg:
Advancing the weak leg first and then the strong leg is not the proper technique for using a cane. The correct method is to hold the cane on the stronger side and move the cane and the weaker leg forward together, followed by the stronger leg.

B. You should advance the cane 12 to 14 inches before taking a step:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.

C. The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.

D. You should hold the cane in your weak hand when ambulating:
The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.

A. The client reports numbness at the site. B. Purulent drainage noted from the site C. Skin over the site is sloughing D. The vein appears cord-like

Correct Answer is B

Explanation

A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.

B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.

C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.

D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.

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A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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