A nurse is caring for a client scheduled for a bone marrow biopsy.
The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?
The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible.
Your provider scheduled this, so she will want to know you still have asks about the procedure.
You will be asleep for the whole biopsy procedure and won't be aware of what's happening.
You must be very worried about what the biopsy will show.
The Correct Answer is A
Choice A rationale
This response acknowledges the client's concern directly and validates their feelings about potential discomfort. It also provides reassurance by stating that measures will be taken to minimize pain, establishing trust and indicating a commitment to patient comfort. This therapeutic communication promotes a sense of control and prepares the client realistically for the procedure, promoting coping mechanisms.
Choice B rationale
This response is dismissive of the client's immediate concerns and shifts responsibility back to the provider, undermining the nurse's role in patient education and support. It does not address the client's anxiety about the procedure itself and can make the client feel unheard and unimportant. The nurse should be capable of addressing common procedure-related questions.
Choice C rationale
Bone marrow biopsies are typically performed under local anesthesia, not general anesthesia, meaning the client will be awake during the procedure, although discomfort will be managed. Providing inaccurate information can lead to a breach of trust and increased anxiety if the client realizes the information was incorrect during the procedure.
Choice D rationale
While the client might be worried about the biopsy results, the direct question was about the pain of the procedure. This response deflects from the immediate concern about physical discomfort and instead interprets the client's underlying emotional state, which is not what was asked. The nurse should directly answer the client's explicit question first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Unilateral calf tenderness is a common symptom of deep vein thrombosis (DVT), a condition involving blood clot formation, often in the leg. While serious, DVT is not a direct common finding indicating cancer, though certain cancers can increase DVT risk due to hypercoagulability. It warrants investigation but is not a primary cancer sign. Normal D-dimer levels are typically less than 0.5 mcg/mL.
Choice B rationale
A nagging cough, especially one that persists for an extended period or changes in character, can be a significant indicator of lung cancer or other respiratory malignancies. Chronic irritation of the airways by a tumor can lead to such a cough, differentiating it from an acute infection. This symptom warrants prompt medical evaluation.
Choice C rationale
A non-healing sore, particularly one that bleeds, changes in appearance, or fails to respond to conventional wound care, is a classic warning sign of skin cancer, such as basal cell carcinoma or squamous cell carcinoma. Cellular proliferation and impaired wound healing mechanisms are often at play in malignant lesions.
Choice D rationale
Unintended weight gain is generally not a common finding that indicates cancer. In fact, unexplained or unintended weight loss is a more frequent paraneoplastic syndrome associated with various malignancies, often due to increased metabolic demands of tumor growth and cachexia.
Choice E rationale
A persistent change in bowel pattern, such as new-onset constipation, diarrhea, or a change in stool caliber, can be a significant symptom of colorectal cancer. Tumors in the bowel can disrupt normal peristalsis and alter absorption, necessitating investigation to rule out malignancy.
Correct Answer is B
Explanation
Choice A rationale
Referring the patient to psychiatry immediately, while potentially necessary later, may not be the most appropriate initial nursing intervention. The patient's feelings of overwhelm and hopelessness are a normal emotional response to a new, chronic diagnosis like multiple sclerosis. A direct and immediate psychiatric referral might feel dismissive of their current emotional state without first addressing their immediate need for information and support, which is within the nurse's scope.
Choice B rationale
Providing information about treatment options and support resources is the most appropriate initial nursing intervention. This empowers the patient by reducing uncertainty and fostering a sense of control. Education on disease progression, symptom management, and available therapies (e.g., immunomodulators) addresses their immediate anxiety about the future. Connecting them with support groups (e.g., National Multiple Sclerosis Society) provides emotional validation and coping strategies from peers.
Choice C rationale
Telling the patient that everything will be fine is an example of false reassurance, which is an ineffective therapeutic communication technique. While well-intentioned, it minimizes the patient's valid feelings of fear and hopelessness associated with a chronic, progressive neurological condition like multiple sclerosis. This approach can lead to a loss of trust between the patient and nurse, making the patient feel misunderstood and isolated.
Choice D rationale
Encouraging the patient to accept the diagnosis, while a long-term goal, is not the most appropriate initial intervention. Acceptance is a process that unfolds over time and often follows stages of grief. Directly telling someone to accept a new, life-altering diagnosis can be perceived as demanding and insensitive. The immediate focus should be on providing support, information, and resources to help them begin this complex emotional journey at their own pace.
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