A preoperative nurse is caring for a client who is being prepped for emergency surgery related to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?
The most important thing is that now you are here, and it is going to get taken care of.
This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.
I will be happy to go and get you some reading materials about this procedure to explain it further.
It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.
The Correct Answer is B
Choice A Reason: The most important thing is that now you are here, and it is going to get taken care of
While this statement is reassuring, it does not provide the client with the specific information they are seeking about adhesions. Clients often feel more at ease when they understand the cause of their condition. Providing clear and accurate information helps reduce anxiety and empowers the client to be more involved in their care.
Choice B Reason: This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine
This statement is the best response because it directly addresses the client’s question about adhesions. Adhesions are bands of scar tissue that can form after abdominal surgery, causing organs or tissues to stick together. These adhesions can constrict the intestines, leading to a blockage. Providing this explanation helps the client understand the cause of their condition and the reason for the surgery.
Choice C Reason: I will be happy to go and get you some reading materials about this procedure to explain it further
Offering reading materials can be helpful, but it does not immediately address the client’s anxiety or their specific question about adhesions. While additional information can be beneficial, the nurse should first provide a clear and direct explanation to help the client understand their condition.
Choice D Reason: It’s okay. It happens all the time and I’ve seen a lot of clients with this issue
This statement may come across as dismissive and does not provide the client with the information they need. While it is important to reassure the client, it is equally important to provide specific information about their condition. Understanding the cause of their symptoms can help reduce anxiety and improve the client’s overall experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
This option suggests that the gallbladder is blocked by a tumor. While tumors can cause blockages, they are not the most common cause of gallbladder inflammation requiring a cholecystectomy. Gallstones are a more frequent cause of such issues.
Choice B Reason:
This is the correct answer. Gallstones can block the common bile duct, leading to inflammation of the gallbladder, a condition known as cholecystitis. This blockage prevents bile from flowing out of the gallbladder, causing pain and potentially leading to infection.
Choice C Reason:
While cholesterol is a component of many gallstones, the inflammation of the gallbladder is typically due to the physical blockage caused by the stones rather than the cholesterol itself. The blockage leads to bile buildup and subsequent inflammation.
Choice D Reason:
Gallbladder infections caused by viruses are extremely rare. Most gallbladder infections are bacterial and occur secondary to blockages caused by gallstones.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason: Light sensitivity
Light sensitivity, also known as photophobia, is a common symptom of a ruptured cerebral aneurysm. When an aneurysm ruptures, it can cause bleeding in the brain, leading to increased intracranial pressure and irritation of the meninges, which can result in sensitivity to light.
Choice B Reason: Loss of consciousness
Loss of consciousness is a critical symptom of a ruptured cerebral aneurysm. The sudden increase in intracranial pressure from the bleeding can lead to a rapid decline in the patient’s level of consciousness. This symptom is a medical emergency and requires immediate attention.
Choice C Reason: A dilated pupil
A dilated pupil can indicate increased intracranial pressure or direct pressure on the cranial nerves due to the bleeding from a ruptured aneurysm. This symptom is often associated with severe neurological impairment and requires urgent medical intervention.
Choice D Reason: Visual disturbances
Visual disturbances, such as blurred or double vision, can occur due to the pressure exerted by the bleeding on the optic nerves or other parts of the visual pathway. These disturbances are significant indicators of neurological compromise.
Choice E Reason: Nausea and vomiting
Nausea and vomiting are common symptoms of increased intracranial pressure, which can result from a ruptured cerebral aneurysm. The irritation of the brain’s vomiting center due to the bleeding can lead to these symptoms.
Choice F: Numbness on one side of the face
Numbness on one side of the face is not typically a direct symptom of a ruptured cerebral aneurysm. While neurological deficits can occur, numbness is more commonly associated with other types of strokes or localized nerve damage rather than the acute presentation of a ruptured aneurysm.
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