A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.
The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.
Which of the following statements is the best response from the nurse?
“This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”.
“The most important thing is that now you are here, and it is going to get taken care of.”.
“I will be happy to go and get you some reading materials about this procedure to explain it further.”.
“It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.
The Correct Answer is A
Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
After a total hip arthroplasty, it is important to prevent hip dislocation. One way to do this is to place a wedge pillow between the legs. This helps to keep the hip in a stable position and prevents the hip from moving too much, which could lead to dislocation.
Correct Answer is C
Explanation
Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
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