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 ["21"]
Explanation
Let’s calculate the infusion rate step by step:
- Convert 1 liter to mL: 1 liter = 1000 mL.
- Calculate total infusion time in minutes: 12 hours = 12 × 60 = 720 minutes.
- Calculate the rate in mL/min: Rate = Total Volume ÷ Total Time = 1000 mL ÷ 720 min = 1.39 mL/min.
- Calculate the drip rate in gtt/min: Drip Rate = Rate (mL/min) × Drip Factor (gtt/mL) = 1.39 mL/min × 15 gtt/mL = 20.85 gtt/min.
If rounding is required, we round to the nearest whole number. So, the nurse should regulate the infusion to 21 gtt/min.
Correct Answer is C
Explanation
Choice A rationale:
Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.
Choice B rationale:
Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Choice C rationale:
Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.
Choice D rationale:
Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
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