A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?
"It must be difficult facing this type of surgery.”
"Other clients who have had this surgery have done just fine.”
"This facility is known for providing excellent care for people who need this type of surgery.”
"I can request a sleeping pill if you think that will help.”
The Correct Answer is A
The correct answer is choice a. "It must be difficult facing this type of surgery.”
Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.
Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.
Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.
Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: A thready pulse.
Choice A rationale:
BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.
Choice B rationale:
A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.
Choice C rationale:
Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.
Choice D rationale:
Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
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