A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, "I'm worried about that bag." Which of the following is an appropriate response by the nurse?
"Have you ever known someone who has a colostomy?
"Let's wait until after the surgery to discuss your concerns about your colostomy."
"You are worried about having to wear a colostomy bag?"
"The surgeon will only place the colostomy if it is necessary.”
The Correct Answer is C
The nurse's response demonstrates active listening and empathy, acknowledging the client's concerns and addressing them directly. It allows the client to express their worries and opens up a dialogue for further discussion and support. This response shows that the nurse is attentive to the client's emotions and is ready to provide information and reassurance regarding the colostomy. It also encourages the client to openly discuss their fears and concerns, which can help alleviate anxiety and promote a trusting nurse-client relationship.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse's priority finding in this case would be a change in appearance of a mole on the shoulder. Changes in the appearance of moles can be an indication of skin cancer or melanoma, which is a serious and potentially life-threatening condition. It is important for the nurse to assess the mole further and report any concerning changes to the healthcare provider for appropriate evaluation and management. The other findings, such as skin tags, a flat discolored area of skin, or atrophic fingers, may require further assessment and interventions, but they are not as immediately concerning as a potential change in a mole that could indicate skin cancer.
Correct Answer is A
Explanation
When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.
Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.
Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.
Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.
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