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 A
Explanation
A) Correct- Clients with Parkinson's disease often experience bradykinesia and impaired mobility. Rising slowly from a seated position is important to prevent falls and maintain stability. Affirming the correct movement strategy promotes the client's safety.
B) Incorrect- Telling the UAP to make the client move more quickly could be unsafe and not appropriate for a client with Parkinson's disease. Rapid movements might lead to balance issues or falls.
C) Incorrect- While demonstrating proper technique might be helpful, it's not the most immediate action the nurse should take. The client's safety and well-being are the priority.
D) Incorrect- Painful movement is not the primary issue here. The client's movement is slow due to Parkinson's disease, and this is expected.
Correct Answer is B
Explanation
This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.
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