A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?
Offer information about alternative therapies to the procedure.
Contact a family member to convince the client to change their mind.
Tell the client the benefits of the surgery.
Notify the charge nurse of the client's concerns.
The Correct Answer is D
The correct answer is choice d. Notify the charge nurse of the client’s concerns.
Choice A rationale:
Offering information about alternative therapies is not appropriate in this situation. The nurse’s role is to ensure the client understands the current procedure and to address their concerns, not to suggest alternatives unless directed by the healthcare provider.
Choice B rationale:
Contacting a family member to convince the client to change their mind is not ethical. The decision to proceed with surgery should be made by the client, based on their understanding and consent, not under pressure from family members.
Choice C rationale:
Telling the client the benefits of the surgery might be helpful, but it does not address the client’s lack of understanding about the procedure. The nurse should ensure the client has all the necessary information to make an informed decision.
Choice D rationale:
Notifying the charge nurse of the client’s concerns is the correct action. The charge nurse can facilitate further discussion with the surgeon to ensure the client receives the necessary information and support to make an informed decision. This ensures that the client’s autonomy and right to informed consent are respected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A - Measure the client's gastric residual before each feeding.
Choice A rationale:
The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.
Choice B rationale:
Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.
Choice C rationale:
Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.
Choice D rationale:
Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.
Correct Answer is A
Explanation
The correct answer is choice A. Ego integrity vs. despair.
Choice A rationale:
Erikson's Theory of Psychosocial Development outlines various stages of development that individuals go through across their lifespan. In the final stage, which occurs in late adulthood, individuals either experience a sense of ego integrity or despair. Ego integrity is characterized by a sense of fulfillment and satisfaction with one's life choices, while despair is marked by feelings of regret and a sense of unfulfillment. The older adult client expressing that their life has no purpose suggests a struggle with finding meaning and satisfaction, aligning with the ego integrity vs. despair stage.
Choice B rationale:
Generativity vs. self-absorption is a stage that occurs during middle adulthood. It involves concerns about contributing to society and the next generation. This stage is not applicable to the scenario described with an older adult who is grappling with a lack of purpose in life.
Choice C rationale:
Identity vs. role confusion is a stage that occurs during adolescence, where individuals explore their sense of self and develop their identities. This stage is not relevant to the older adult client's situation of feeling purposeless.
Choice D rationale:
Intimacy vs. isolation is a stage that typically occurs during young adulthood, where individuals seek close and meaningful relationships with others. This stage is not appropriate for the older adult's feelings of lacking purpose.
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