The nurse is performing discharge teaching for a patient who has had major abdominal surgery.
Which statement or question by the nurse would be appropriate?
"You don't need to worry about anything.
We will get home health care set up for you.”.
"I heard your son was arrested for driving while intoxicated, will he be there to help you care for your incision?".
"I am sure you can't wait to go home.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ethical dilemma involves a situation in which a person is faced with conflicting moral principles, making it difficult to choose the right course of action. In this scenario, the nurse is not dealing with conflicting moral principles but rather providing information about end-of-life care options, demonstrating respect for the patient's autonomy.
Choice B rationale:
Nonmaleficence is the principle of doing no harm. While it is an important ethical principle in nursing, it does not directly apply to the situation described. The nurse is not making decisions that could harm the patient but is instead providing information and support regarding end-of-life care options.
Choice C rationale:
Autonomy refers to the right of individuals to make their own decisions about their own lives and bodies, even if those decisions are not in their best interest according to others. In this scenario, the nurse is respecting the patient's autonomy by providing information and discussing various care options, allowing the patient to make informed decisions about their end-of-life care.
Choice D rationale:
Social justice involves promoting fairness and equity in the distribution of resources and opportunities. While social justice is an important nursing value, it does not directly apply to the situation described. The nurse is primarily focused on respecting the patient's autonomy and providing information about end-of-life care options.
Correct Answer is C
Explanation
Choice A rationale:
Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.
Choice B rationale:
Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.
Choice C rationale:
Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.
Choice D rationale:
Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.
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