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 D
Explanation
Choice A Reason: Night sweats
Night sweats are not typically associated with liver disease. They are more commonly linked to conditions such as infections, hormonal imbalances, or certain cancers1. While liver disease can cause a variety of symptoms, night sweats are not a primary manifestation.
Choice B Reason: Acanthosis nigricans
Acanthosis nigricans is characterized by dark, velvety patches of skin, usually in body folds and creases. It is often associated with insulin resistance, obesity, and certain endocrine disorders. It is not a common manifestation of liver disease.
Choice C Reason: Hemosiderin staining
Hemosiderin staining refers to the deposition of iron in the skin, which can cause a brownish discoloration. This condition is more commonly associated with chronic venous insufficiency or hemochromatosis, a genetic disorder that causes iron overload. It is not a typical symptom of liver disease.
Choice D Reason: Pruritus
Pruritus, or itching, is a common symptom of liver disease. It is often caused by the accumulation of bile salts in the skin due to impaired bile flow, a condition known as cholestasis. This symptom can be particularly distressing for patients and is a significant indicator of liver dysfunction.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Rubeola, also known as measles, is highly contagious and spreads through airborne transmission. The virus can remain infectious in the air for up to two hours after an infected person coughs or sneezes. This makes it one of the most easily spread diseases through airborne particles.
Choice B Reason:
Clostridium difficile (C. diff) is primarily transmitted through the fecal-oral route, not through airborne transmission. It spreads via spores that can survive on surfaces and be ingested, leading to infection.
Choice C Reason:
Varicella, or chickenpox, is transmitted through airborne particles. The virus can spread through direct contact with the fluid from the blisters or through respiratory droplets when an infected person coughs or sneezes. This makes it an airborne disease.
Choice D Reason:
Tuberculosis (TB) is caused by Mycobacterium tuberculosis and spreads through the air when an infected person coughs, speaks, or sings. The bacteria can remain suspended in the air for several hours, making TB an airborne disease.
Choice E Reason:
Staphylococcus aureus is not typically transmitted through airborne means. It spreads through direct contact with infected wounds, contaminated surfaces, or through respiratory droplets in some cases. However, it is not considered an airborne disease.
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