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 D
Explanation
A. Gonorrhea: While sexually transmitted infections can affect pregnancy, the symptoms described are not consistent with gonorrhea.
B. Group B Streptococcus: Group B Streptococcus is commonly screened for in pregnant individuals but does not typically present with the described symptoms.
C. Toxoplasmosis: Toxoplasmosis can affect pregnancy, but the symptoms described are not specific to toxoplasmosis.
D. Rubella: Rubella infection during pregnancy can lead to congenital rubella syndrome, which can cause birth defects. The symptoms described are consistent with rubella infection.
Correct Answer is B
Explanation
A. Decreased level of consciousness: While altered mental status can occur in clients with cirrhosis, it is not directly related to recent weight gain.
B. Increased abdominal girth: Weight gain in clients with cirrhosis can be due to fluid retention, which often manifests as increased abdominal girth.
C. Increased respiratory rate: Respiratory rate is not typically directly correlated with recent weight gain in clients with cirrhosis.
D. Decreased bowel sounds: While bowel sounds may be decreased in clients with cirrhosis, they are not directly related to recent weight gain.
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