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
Explanation
A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.
Correct Answer is ["A","B","D"]
Explanation
A) Correct - Providing contact information for community resources is important as it ensures that parents have access to support and information beyond the hospital setting.
B) Correct - Offering information about pool safety is relevant, especially considering that the child experienced a submersion injury. This education can help prevent future accidents.
C) Incorrect - While discussing child neglect is important, it may not be the most appropriate time to bring up potential charges. The immediate focus should be on education and support.
D) Correct - Informing parents about when to follow up with the child's pediatrician ensures continuity of care and monitoring of the child's condition after discharge.
E) Incorrect - Instructions on how to access long-term home care may not be necessary if the child's condition does not warrant it. This option can be excluded based on the information provided.
F) Incorrect - Assessing the parent's coping skills is important, but it is not part of pre- discharge education. Education related to the child's condition and safety is more pertinent.
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