At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?
Knowledge deficit.
Anxiety.
Pain intolerance.
Anticipatory grieving.
The Correct Answer is B
Choice B is correct because anxiety is the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anxiety is a feeling of fear, nervousness, or apprehension that can interfere with coping and decision making. The nurse should assess the level and source of anxiety and provide emotional support and reassurance to the client. The nurse should also review the pain management techniques and explain the benefits and risks of different analgesic options.
Choice A is incorrect because knowledge deficit is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Knowledge deficit is a lack of information or understanding about a topic or situation that can affect learning and behavior. The nurse should evaluate the client's learning needs and provide appropriate education and resources, but this is not as urgent as addressing the client's anxiety.
Choice C is incorrect because pain intolerance is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Pain intolerance is an inability or unwillingness to endure pain that can affect quality of life and recovery. The nurse should assess the client's pain level and response to analgesics and adjust the pain management plan accordingly, but this is not as urgent as addressing the client's anxiety.
Choice D is incorrect because anticipatory grieving is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anticipatory grieving is a process of mourning that occurs before an expected loss or death that can affect emotional and physical well-being. The nurse should acknowledge the client's feelings and provide empathy and support, but this is not as urgent as addressing the client's anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
Correct Answer is C
Explanation
Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
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