A nurse is caring for a client who is scheduled for a colostomy. The client tells the nurse to cancel the procedure. Which of the following responses should the nurse make?
"Why have you decided not to have the procedure?"
"Don't worry. You will adjust to the colostomy quickly."
"It sounds like you have concerns about the procedure."
"Do you think that's the right decision for you and your family?"
The Correct Answer is C
Answer: C
Rationale:
C) "It sounds like you have concerns about the procedure."
This response is therapeutic and encourages the client to express their concerns, allowing the nurse to understand the client's feelings without judgment. It opens up a supportive dialogue where the client can discuss their fears, anxieties, or misconceptions about the colostomy, which can then be addressed appropriately.
A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.
B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.
D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
"Gather enough supplies to last for 2 weeks": This information is essential for disaster preparedness. During emergencies, such as natural disasters or pandemics, access to resources may be limited for an extended period. Having a sufficient supply of food, water, medications, and other essentials for at least two weeks ensures that older adults can sustain themselves until assistance becomes available.
C) "Have a backup supply of nonprescription medications": It is crucial for older adults to have a backup supply of nonprescription medications, such as pain relievers, antacids, or allergy medications, in case they are unable to access pharmacies during a disaster. Having these medications readily available can help manage common health issues that may arise during emergencies.
D) "Stock 2 liters of water per person per day": Adequate hydration is essential for maintaining health, especially during emergencies when access to clean water may be disrupted. Older adults are particularly vulnerable to dehydration, so having a sufficient supply of water—approximately 2 liters per person per day—for drinking, cooking, and hygiene purposes is critical for their well-being.
Correct Answer is C
Explanation
A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.
B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.
C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.
D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.
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