A preoperative nurse is caring for a client who is being prepped for emergency surgery related 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?
The most important thing is that now you are here, and it is going to get taken care of.
This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.
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 B
Choice A Reason: The most important thing is that now you are here, and it is going to get taken care of
While this statement is reassuring, it does not provide the client with the specific information they are seeking about adhesions. Clients often feel more at ease when they understand the cause of their condition. Providing clear and accurate information helps reduce anxiety and empowers the client to be more involved in their care.
Choice B Reason: This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine
This statement is the best response because it directly addresses the client’s question about adhesions. Adhesions are bands of scar tissue that can form after abdominal surgery, causing organs or tissues to stick together. These adhesions can constrict the intestines, leading to a blockage. Providing this explanation helps the client understand the cause of their condition and the reason for the surgery.
Choice C Reason: I will be happy to go and get you some reading materials about this procedure to explain it further
Offering reading materials can be helpful, but it does not immediately address the client’s anxiety or their specific question about adhesions. While additional information can be beneficial, the nurse should first provide a clear and direct explanation to help the client understand their condition.
Choice D Reason: It’s okay. It happens all the time and I’ve seen a lot of clients with this issue
This statement may come across as dismissive and does not provide the client with the information they need. While it is important to reassure the client, it is equally important to provide specific information about their condition. Understanding the cause of their symptoms can help reduce anxiety and improve the client’s overall experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
An N95 respirator is used for airborne precautions, not contact precautions. It is necessary for protecting against airborne pathogens like tuberculosis or COVID-19.
Choice B Reason:
Goggles are used to protect the eyes from splashes or sprays of infectious materials. While they can be part of contact precautions, they are not the primary PPE required for changing bed linen.
Choice C Reason:
A face shield provides protection against splashes and sprays to the face. Similar to goggles, it is not the primary PPE required for contact precautions when changing bed linen.
Choice D Reason:
This is the correct answer. Gloves are essential for contact precautions to prevent the transmission of infectious agents through direct or indirect contact with contaminated surfaces or materials. They protect the nurse from coming into contact with pathogens that may be present on the bed linen.
Correct Answer is A
Explanation
Choice A Reason: Portal of entry
The client’s mouth serves as the portal of entry in the chain of infection. The portal of entry is the route through which an infectious agent enters the host. In the case of hepatitis A, the virus enters the body through the mouth when contaminated food or water is ingested. This link is crucial in the chain of infection as it determines how the pathogen gains access to the host’s body.
Choice B Reason: Susceptible host
A susceptible host is an individual who is at risk of infection due to factors such as a weakened immune system, age, or underlying health conditions. While the client in this scenario may be a susceptible host, the mouth specifically represents the portal of entry, not the host itself.
Choice C Reason: Infectious agent
The infectious agent is the pathogen that causes the disease. In this case, the infectious agent is the hepatitis A virus. The mouth is not the infectious agent but rather the entry point for the virus into the body.
Choice D Reason: Reservoir
A reservoir is the habitat in which the infectious agent normally lives, grows, and multiplies. Common reservoirs include humans, animals, and the environment. The client’s mouth is not a reservoir but the portal of entry for the hepatitis A virus.
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