When the practical nurse (PN) atempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!"
Which response is best for the PN to make?
A. "You must ambulate to avoid complications which could cause more discomfort than ambulating."
B. "I know you feel angry about the pain of ambulation, but this is a necessary part of getting well."
C. "Your healthcare provider has left specific instructions to ambulate on the first postoperative day."
D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."
The Correct Answer is D
An 18-year-old client with a mild mental disability is a client who has a lower than average intellectual functioning and some limitations in adaptive skills, such as communication, socialization, and self-care. A mild mental disability may affect the client's ability to understand, cope, or cooperate with medical interventions, such as ambulation after surgery.
Ambulation is the act of walking or moving around. It is an important part of postoperative care, as it helps to prevent complications such as deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis, constipation, and pressure ulcers. Ambulation also promotes circulation, wound healing, and muscle strength.
When the practical nurse (PN) atempts to assist the client to ambulate on the first postoperative day after an appendectomy, the client becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" This may indicate that the client is experiencing pain, fear, anxiety, or frustration due to the surgery and the recovery process .
The best response for the PN to make is to acknowledge the client's feelings, provide reassurance and support, and set a clear and realistic goal for ambulation. This will help to establish rapport, reduce resistance, and motivate the client to participate in the care plan.
Therefore, option D is the correct answer, as it shows empathy and respect for the client's feelings, while also informing the client of the expectation and time frame for ambulation. Option D also allows the client some time to prepare mentally and physically for the activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Procure platelet products from the blood bank. Rationale: Procuring platelet products from the blood bank is a specialized task that requires specific training and authorization. It should be performed by licensed healthcare providers, such as nurses or physicians, rather than unlicensed assistive personnel (UAP).
Choice B rationale:
Titrate oxygen to the prescribed parameters. Rationale: Titrating oxygen to prescribed parameters requires clinical judgment and assessment skills, which are beyond the scope of practice for UAP. This task should be performed by licensed nurses or respiratory therapists.
Choice C rationale:
Monitor an intravenous infusion rate on an established schedule. Rationale: This is the correct answer. UAP can be trained to monitor intravenous (IV) infusion rates on an established schedule for clients who do not require complex adjustments. It is within their scope of practice to ensure that the IV is running at the prescribed rate and to report any abnormalities or concerns to the nursing staff.
Choice D rationale:
Insert a urinary catheter for an uncomplicated client. Rationale: Inserting a urinary catheter is a specialized nursing procedure that should only be performed by licensed nurses or healthcare providers. It is not within the scope of practice for UAP, even for uncomplicated cases.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.
Choice B rationale:
Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.
Choice C rationale:
The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.
Choice D rationale:
While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.
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