An older adult client returned to the nursing home after a lower limb amputation. The client is scheduled for a prosthesis fitting and states, “I am too old to learn how to manage this.” Which of the following responses from the nurse is appropriate?
I will call your provider so we can discuss it.
What are you thinking that you would like to do?
You have the right to refuse if you don’t think you can do this.
Many clients your age are able to adjust surprisingly well to a prosthesis.
The Correct Answer is D
Choice A Reason: I will call your provider so we can discuss it
While this response shows the nurse’s willingness to involve the healthcare provider, it does not directly address the client’s concern about their ability to manage the prosthesis. It is important to provide immediate reassurance and encouragement to the client, which this response lacks.
Choice B Reason: What are you thinking that you would like to do?
This response is open-ended and encourages the client to express their feelings and thoughts. While it is a good approach to understand the client’s perspective, it does not provide the immediate reassurance and encouragement that the client needs to feel confident about managing the prosthesis.
Choice C Reason: You have the right to refuse if you don’t think you can do this
This response acknowledges the client’s autonomy but may inadvertently reinforce their doubts and fears about managing the prosthesis. It is important to encourage and support the client rather than focusing on their right to refuse.
Choice D Reason: Many clients your age are able to adjust surprisingly well to a prosthesis
This response is the most appropriate as it provides reassurance and encouragement to the client. By sharing that many clients of a similar age have successfully adjusted to a prosthesis, the nurse helps to build the client’s confidence and reduce their anxiety about managing the new situation. This positive reinforcement can be very motivating for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A healthy stoma should be pink or red, not purple. A purple stoma could indicate compromised blood flow and requires immediate medical attention.
Choice B Reason:
A sigmoid colostomy typically produces formed stool because it is located in the lower part of the colon, where water absorption occurs.
Choice C Reason:
The stoma itself should not be painful after the procedure. Pain may indicate complications such as infection or improper stoma care.
Choice D Reason:
This is the correct answer. A sigmoid colostomy is usually located in the left lower abdomen, as this is where the sigmoid colon is situated.
Correct Answer is A
Explanation
Choice A Reason: Portal of entry
The client’s mouth serves as the portal of entry in the chain of infection. The portal of entry is the route through which an infectious agent enters the host. In the case of hepatitis A, the virus enters the body through the mouth when contaminated food or water is ingested. This link is crucial in the chain of infection as it determines how the pathogen gains access to the host’s body.
Choice B Reason: Susceptible host
A susceptible host is an individual who is at risk of infection due to factors such as a weakened immune system, age, or underlying health conditions. While the client in this scenario may be a susceptible host, the mouth specifically represents the portal of entry, not the host itself.
Choice C Reason: Infectious agent
The infectious agent is the pathogen that causes the disease. In this case, the infectious agent is the hepatitis A virus. The mouth is not the infectious agent but rather the entry point for the virus into the body.
Choice D Reason: Reservoir
A reservoir is the habitat in which the infectious agent normally lives, grows, and multiplies. Common reservoirs include humans, animals, and the environment. The client’s mouth is not a reservoir but the portal of entry for the hepatitis A virus.
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