The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
The client will demonstrate ability to change the ostomy bag in two days.
The client will adhere to the medication regimen after discharge.
The client's breath sounds will be auscultated by the nurse every 4 hours.
The client attempts to self administer insulin but is unable to perform injection.
None
None
The Correct Answer is B
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Related Questions
Correct Answer is C
Explanation
A. "This unit has a policy against staff harassment."
This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.
B. "It is important to dress the right arm first."
This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.
C. "Dressing must be a frustrating experience for you."
This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.
D. "We will give you a class on dressing tomorrow."
This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.
Correct Answer is C
Explanation
In this situation, the best approach for the nurse to use when questioning the client about sexual activity is:
A. Ask questions in a vague, nonspecific format.
This approach may lead to confusion or misunderstanding on the part of the client and may not elicit the necessary information about sexual activity. It's important for the questions to be clear and specific to ensure accurate assessment and appropriate care.
B. Get the most difficult questions over with first.
Starting with the most difficult or sensitive questions may put the client on the defensive or make them feel uncomfortable. It's generally more effective to build rapport and trust with the client before broaching sensitive topics.
C. Begin with questions that are less sensitive in nature.
This approach allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as sexual activity. Starting with less sensitive questions can help the client feel more comfortable and open up about their concerns.
D. Share personal values to put the client at ease.
Sharing personal values may not be appropriate or helpful in this context, as it could potentially influence the client's responses and compromise the objectivity of the assessment. The focus should be on creating a safe and supportive environment for the client to discuss their health concerns without feeling judged.
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