While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?
Attempt to distract the client with general conversation.
Explain the procedure in detail while removing the staples.
Encourage the client to continue to verbalize the anxiety.
Reassure the client that this is a simple nursing procedure.
The Correct Answer is A
A. Attempting to distract the client with general conversation can help redirect the client's focus away from the discomfort and anxiety associated with the procedure. It can help alleviate anxiety and make the experience more tolerable for the client.
B. Explaining the procedure in detail while removing the staples may increase the client's anxiety and discomfort. While education about the procedure is important, it may not be the most
effective intervention in this situation.
C. Encouraging the client to continue to verbalize the anxiety acknowledges the client's feelings but may not effectively address the anxiety or alleviate discomfort during the procedure.
D. Reassuring the client that this is a simple nursing procedure may not be sufficient to alleviate the client's anxiety. The client's perception of the procedure as distressing is valid, and additional measures may be needed to help manage the anxiety and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.
Correct Answer is D
Explanation
A. Ankle edema and varicose veins are more commonly associated with venous insufficiency rather than peripheral arterial disease. Asking about these symptoms may not provide relevant information about chronic arterial symptoms.
B. Weeping ulcers on the lower legs are more indicative of venous insufficiency rather than peripheral arterial disease. Asking about these ulcers may not provide relevant information about chronic arterial symptoms.
C. Sudden onset of leg swelling, redness, warmth, and pain is suggestive of acute arterial occlusion rather than chronic arterial symptoms. Asking about these symptoms may be important for assessing acute arterial events, but it does not specifically address chronic arterial symptoms.
D. Peripheral arterial disease commonly presents with intermittent claudication, which causes calf pain or discomfort during physical activity, such as walking short distances. Asking about calf pain during walking can help assess for symptoms of peripheral arterial disease and its
impact on mobility and quality of life.
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