A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?

Describe the surgery and what the client will experience postoperatively.

Reinforce information at the client's level of understanding.

Reassure the client that the surgery rarely has any negative outcomes.

Notify the client's family of the plan of care.

Answer and Explanation

The Correct Answer is B

A) Describe the surgery and what the client will experience postoperatively:
While it is essential to provide information about the surgery and the postoperative experience, the primary focus of preoperative teaching is to ensure that the client understands the information provided. This option does not specifically address the client's level of understanding, which is crucial for effective teaching.

B) Reinforce information at the client's level of understanding:
This is the correct choice. When contributing to the preoperative teaching plan, the nurse should ensure that information is provided in a way that the client can comprehend. Reinforcing information at the client's level of understanding enhances communication and ensures that the client is well-informed about the procedure and what to expect.

C) Reassure the client that the surgery rarely has any negative outcomes:
While it is important to provide reassurance and support to the client, it is not appropriate to make promises or provide guarantees about the outcome of the surgery. Surgery, by its nature, carries risks, and it is essential to provide the client with accurate information while maintaining a supportive and empathetic approach.

D) Notify the client's family of the plan of care:
While it is important to involve the client's family in the plan of care, the primary focus of preoperative teaching is on the client. Involving the family in the plan of care is important, but it is not the most immediate action in the context of preoperative teaching.

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Correct Answer is A

Explanation

Answer: A. An adolescent who asks to stay in the hospital because he likes the room

Rationale:

A) An adolescent who asks to stay in the hospital because he likes the room: This finding may indicate that the adolescent is experiencing abuse or neglect at home. A desire to remain in the hospital could suggest that the child views it as a safe space compared to their home environment, warranting further assessment for possible abuse.

B) A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruising on the shins is common in toddlers due to normal exploratory behavior and frequent falls. The parent's explanation aligns with developmental norms, making this finding less indicative of abuse.

C) A school-age child who cries when the nurse is giving him an injection: Crying during injections is a typical reaction for school-age children and does not suggest abuse. Emotional responses to medical procedures are age-appropriate and expected.

D) A preschooler who has a BMI indicating obesity: While obesity in children may raise concerns about diet and lifestyle, it is not inherently indicative of abuse. Further evaluation may be needed for nutritional and health interventions but does not typically suggest maltreatment.

A. Tingling of the lips B. Hypoactive bowel sounds C. Skeletal muscle weakness D. Decreased deep-tendon reflexes

Correct Answer is A

Explanation

A) Tingling of the lips:
This is the correct choice. Hypocalcemia, which is low calcium levels in the blood, can lead to neurological symptoms such as tingling sensations around the lips and in the extremities. This occurs due to the effect of low calcium levels on the nervous system.

B) Hypoactive bowel sounds:
Hypocalcemia primarily affects neuromuscular function rather than gastrointestinal function. While calcium imbalances can impact gastrointestinal motility, hypoactive bowel sounds are not typically associated with hypocalcemia.

C) Skeletal muscle weakness:
Skeletal muscle weakness is a common symptom of hypocalcemia. Low calcium levels affect the ability of muscles to contract effectively, leading to weakness and fatigue.

D) Decreased deep-tendon reflexes:
Hypocalcemia can actually lead to increased deep-tendon reflexes rather than decreased reflexes. Calcium plays a role in neuromuscular transmission, and low levels can result in hyperexcitability of nerves, leading to increased reflexes rather than decreased reflexes.

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A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?

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