A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

"I will have the nursing staff check on you frequently during the night."

"You are right to be afraid. This is a new place for you."

"I will give you your prescribed sleeping medication to help you fall asleep."

"Describe your concerns about sleeping to me.”

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears. This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

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Correct Answer is D

Explanation

The correct answer is: d. Remove the staple from the skin after both sides are visible.

Explanation: This statement is correct because the staple should be removed only when both sides are visible, ensuring that it has been fully lifted away from the skin. This helps minimize tissue damage and pain while preventing infection.

Choice A Rationale: Lifting the staple remover when squeezing the handle could potentially disrupt the proper angle required for effective staple removal. Staples are designed to be removed in a specific manner to minimize tissue trauma and discomfort to the patient. If the staple remover is lifted while squeezing the handle, it may cause uneven pressure on the staple legs, leading to improper removal. This could result in tissue damage, increased pain for the patient, and potentially leave parts of the staple embedded in the skin, increasing the risk of infection or delayed healing.

Choice B Rationale: Avoiding completely closing the handle after squeezing may not provide sufficient force to properly remove the staple from the skin. Staples are designed to be squeezed closed completely to ensure that they are securely grasped and removed from the incision site. Failing to fully close the handle after squeezing may result in inadequate removal of the staple, leaving parts of it behind in the skin. This can increase the risk of infection, tissue irritation, and delayed wound healing. Additionally, incomplete closure of the handle may lead to discomfort for the patient as the staple removal process may be prolonged or require additional attempts.

Choice C Rationale: Expecting the staples to bend at each outer side during removal is incorrect. Staples are designed to bend in the middle when properly removed from the skin. If the outer sides of the staple were expected to bend, it may indicate improper technique or the use of a faulty staple remover. Staples are intended to be removed smoothly without excessive bending or twisting to minimize trauma to the surrounding tissue and reduce the risk of complications such as infection or delayed wound healing. Anticipating bending at the outer sides could lead to unnecessary manipulation of the staple and increase the likelihood of tissue damage or incomplete removal.

Choice D (Correct Answer) Rationale: Removing the staple from the skin only after both sides are visible is the appropriate technique to ensure proper removal without causing unnecessary trauma or discomfort to the patient. When both sides of the staple are visible, it indicates that the staple has been adequately lifted away from the skin, reducing the risk of tissue damage or incomplete removal. This technique allows for a smooth and controlled extraction of the staple, minimizing pain and promoting optimal wound healing. By waiting until both sides are visible, the nurse can confirm that the staple has been fully disengaged from the tissue, reducing the likelihood of complications such as infection or skin irritation.

A. "You will need to sign a consent form before we begin the procedure.” B. "I will place a gel pad directly above your pubic area before I place the probe.” C. "You will need to hold your urine for 1 hour prior to the procedure.” D. "You will receive a contrast dye through an IV catheter prior to the scan.”

Correct Answer is B

Explanation

Choice A rationale:

"You will need to sign a consent form before we begin the procedure." Rationale: While obtaining consent is an essential part of many medical procedures, including a bladder scan, it is not specific to the teaching related to the procedure itself. It addresses the legal and ethical aspect of the procedure but doesn't instruct the client on what to expect during the procedure.

Choice B rationale:

"I will place a gel pad directly above your pubic area before I place the probe." Rationale: This is the correct choice. Placing a gel pad above the pubic area before using the probe is an important step in ensuring proper ultrasound transmission and obtaining accurate results during a bladder scan. The gel pad helps to eliminate air gaps that could interfere with the quality of the scan.

Choice C rationale:

"You will need to hold your urine for 1 hour prior to the procedure." Rationale: Holding urine for an hour before a bladder scan might be required to ensure that the bladder is adequately filled for the scan, but it doesn't address the specific preparation related to the ultrasound procedure itself.

Choice D rationale:

"You will receive a contrast dye through an IV catheter prior to the scan." Rationale: Mentioning contrast dye and IV catheter is not relevant to a bladder scan. Contrast dye is often used in imaging studies like CT scans or angiograms, but not for a routine bladder scan. Therefore, this instruction is unrelated to the procedure in question.

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A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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