A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want anyone to see me with this bag." Which of the following responses should the nurse make?
"Many people have colostomies and they live full lives."
"Would it help to speak with someone else who has a colostomy?"
"Why don't you want people to see the colostomy bag?"
"You shouldn't worry, the colostomy is probably only temporary."
The Correct Answer is A
Correct. This response provides reassurance and normalizes the client's experience by emphasizing that having a colostomy does not prevent individuals from leading fulfilling lives. B. Incorrect. While peer support can be beneficial, this response does not directly address the client's concerns or provide immediate reassurance.
C. Incorrect. This response may put the client on the spot and make them feel uncomfortable discussing their feelings. It's important to respect the client's privacy and autonomy in disclosing their reasons for not wanting others to see the colostomy bag.
D. Incorrect. Making assumptions about the temporary nature of the colostomy without medical confirmation may not be accurate and can contribute to false hope or disappointment if the client's colostomy is permanent. It's important to provide honest and accurate information while being supportive of the client's emotional needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.
Correct Answer is B
Explanation
A. Projection involves attributing one's own unacceptable thoughts or feelings to another person. In this scenario, the client is not blaming others for their behavior but rather providing a reason for their behavior.
B. Rationalization involves providing logical-sounding explanations to justify behavior that might otherwise be unacceptable. The client's explanation that their recent behavior is due to the loss of their job is an example of rationalization.
C. Repression involves blocking out or pushing away unacceptable thoughts or feelings from conscious awareness.
D. Sublimation involves channeling unacceptable impulses or emotions into socially acceptable activities or behaviors.
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