A client states “I don’t want to have surgery.” Which of the following is a therapeutic response to the client?
“Surgery is your only choice. You need this operation.”.
“Whether or not you have the surgery is your choice. What is your understanding of the situation?”.
“I hear you.
I wouldn’t want surgery either.
The Correct Answer is B
What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.
Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.
Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.
Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.
Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.
Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.
Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.
The normal ranges for arterial blood gas (ABG) are:
- pH: 7.35 – 7.45
- pO2: 10 – 14 kPa or 75 – 105 mmHg
- pCO2: 4.5 – 6 kPa or 34 – 45 mmHg
Correct Answer is A
Explanation
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
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