When the practical nurse (PN) attempts 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?
"You must ambulate to avoid complications which could cause more discomfort than ambulating."
"I know you feel angry about the pain of ambulation, but this is a necessary part of getting well."
"Your healthcare provider has left specific instructions to ambulate on the first postoperative day."
"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) attempts 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.
Options A, B, and C are incorrect answers, as they do not address the client's emotional needs or demonstrate effective communication skills.
Option A is incorrect because it uses a threatening tone and does not acknowledge the client's feelings.
Option B is incorrect because it assumes that the client feels angry about the pain of ambulation, which may not be true or helpful.
Option C is incorrect because it appeals to authority and does not explain the rationale or benefits of ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.
Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.
Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.
The other options are not directly related to the immediate decision of administering pain medication:
Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.
A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.
Correct Answer is C
Explanation
The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.
Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.
Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.
Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.
Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.
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