While removing staples from a client's postoperative wound site, the nurse observes that the client's eyes are closed and the client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?

Attempt to distract the client with general conversation.

Explain the procedure in detail while removing the staples.

Encourage the client to continue to verbalize the anxiety.

Reassure the client that this is a simple nursing procedure.

Answer and Explanation

The Correct Answer is A

A.   Attempting to distract the client with general conversation can help redirect the client's focus away from the discomfort and anxiety associated with the procedure. It can help alleviate anxiety and make the experience more tolerable for the client.
B.   Explaining the procedure in detail while removing the staples may increase the client's anxiety and discomfort. While education about the procedure is important, it may not be the most
effective intervention in this situation.
C.   Encouraging the client to continue to verbalize the anxiety acknowledges the client's feelings but may not effectively address the anxiety or alleviate discomfort during the procedure.
D.   Reassuring the client that this is a simple nursing procedure may not be sufficient to alleviate the client's anxiety. The client's perception of the procedure as distressing is valid, and additional measures may be needed to help manage the anxiety and discomfort.

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Correct Answer is C

Explanation

A. Encouraging the client to participate in group activities may be beneficial but may not address the immediate need for increased communication and engagement.
B. Scheduling a daily conference with the social worker may provide support but may not directly address the client's withdrawal and noncommunicative behavior.
C. Engaging the client in non-threatening conversations is important to assess the client's current emotional state, understand the reasons for withdrawal, and provide support and encouragement for communication and interaction.
D. Encouraging the client's family to visit more often may be helpful for social support, but it may not address the underlying issue of the client's withdrawal and noncommunicative behavior.

A. Acknowledge that the PN has positioned the client safely and correctly. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Assume care of the client and assign the PN to the care of a different client. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

- A: This choice is incorrect because a flat prone position is not safe or correct for a sigmoidoscopy; the client should be in a left lateral or Sims' position.
- B: This choice is not directly related to the immediate need of correcting the client's position for the procedure.
- C: Assuming care of the client does not address the immediate issue of the client's incorrect positioning for the sigmoidoscopy.
- D: Demonstrating the correct positioning ensures the safety and effectiveness of the procedure, which is the nurse's responsibility.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which Intervention is most important to include in the updated plan of care for this client?

Correct Answer is C

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review?

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Exhibits Review History and Physical, and laboratory results. Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

The nurse is conducting Intake Interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?