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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Localized edema:
Localized edema, especially when accompanied by erythema (redness), warmth, and tenderness, can be indicative of an infection in a client with diabetes mellitus. Infections in diabetic patients, particularly those affecting the feet, can lead to localized inflammation and swelling.
B. An increase in RBCs:
An increase in red blood cells (RBCs), known as erythrocytosis, is not typically associated with an infection. Erythrocytosis may occur in conditions such as polycythemia vera or chronic hypoxemia but is not a typical marker of infection.
C. Bradycardia:
Bradycardia, a heart rate slower than the normal range, is not typically associated with infections. Infections often cause tachycardia (an increased heart rate) as part of the body's systemic inflammatory response.
D. An increase in platelets:
An increase in platelets, known as thrombocytosis, is not typically associated with infections. Thrombocytosis can occur in response to various factors, including inflammation, but it is not a specific marker of infection in diabetic clients with foot pain.
E. An increase in neutrophils:
An increase in neutrophils, known as neutrophilia, is a common response to infection. Neutrophils are a type of white blood cell involved in the body's immune response to bacterial infections. In diabetic clients with foot pain, an elevated neutrophil count may suggest the presence of an infection, as the body mobilizes these cells to combat the invading pathogens.
Correct Answer is ["A","C"]
Explanation
A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.
C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.
B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.
D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.