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 C
Explanation
Choice A Reason:
Encouraging the client to bear down is not an appropriate response to abdominal cramps during an enema. Bearing down can increase discomfort and does not address the underlying cause of the cramps.
Choice B Reason:
Stopping the enema and documenting that the client did not tolerate the procedure is not the best initial action. While it is important to document the client’s response, there are other steps that can be taken to alleviate the discomfort before stopping the procedure entirely.
Choice C Reason:
This is the correct answer. Lowering the height of the solution container will reduce the flow rate of the enema solution, which can help alleviate abdominal cramps. A slower flow rate is less likely to cause cramping and discomfort.
Choice D Reason:
Allowing the client to expel some fluid before continuing can help relieve discomfort, but it is not the most immediate or effective action. Adjusting the flow rate by lowering the height of the solution container is a more direct way to address the issue.
Correct Answer is D
Explanation
Choice A Reason: Parent who has cardiovascular disease
Having a parent with cardiovascular disease is considered a non-modifiable risk factor. This means it is related to genetic predisposition and cannot be changed or controlled by the individual. While family history is important in assessing stroke risk, it is not something that can be modified through lifestyle changes or medical interventions.
Choice B Reason: Client’s age
Age is another non-modifiable risk factor for stroke. The risk of stroke increases with age, but it is not something that can be altered. While age is an important consideration in stroke risk assessment, it is not a factor that can be modified to reduce the risk.
Choice C Reason: History of sickle cell disease
Sickle cell disease is a genetic disorder that affects the shape and function of red blood cells. It is a non-modifiable risk factor for stroke because it is inherited and cannot be changed. While managing sickle cell disease can help reduce complications, the condition itself remains a fixed risk factor.
Choice D Reason: Hypertension
Hypertension, or high blood pressure, is a significant modifiable risk factor for stroke. It can be managed and controlled through lifestyle changes such as diet, exercise, and medication. Lowering blood pressure can significantly reduce the risk of stroke, making it a key focus in stroke prevention efforts.
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