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 D
Explanation
Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.
Correct Answer is D
Explanation
Choice A rationale
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
Choice B rationale
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
Choice C rationale
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
Choice D rationale
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.
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