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 D

Explanation

- Choice A Rationale: Assuming care of the client and assigning the PN to another client would disrupt the workflow and could lead to confusion. It is important for continuity of care that the PN who began the procedure with the client carries it through to completion.
- Choice B Rationale: Arranging for unlicensed assistive personnel to assist may not be appropriate as they may not have the training or skills required to assist with a sigmoidoscopy, which could compromise patient safety and the integrity of the procedure.
- Choice C Rationale: Acknowledging that the PN has positioned the client safely and correctly would be incorrect because a flat prone position is not the recommended position for a sigmoidoscopy, which typically requires the client to be in a left lateral or Sims' position.
- Choice D Rationale: Demonstrating to the PN how to position the client more effectively is the correct action because it ensures that the client is in the proper position for a sigmoidoscopy, which can enhance the effectiveness of the procedure and patient comfort.

A. Inform the client that gradual tapering must be used to discontinue the medication. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Remind the client that feeling better is the therapeutic effect of the medication. D. Tell the client to discuss the medication side effects with the healthcare provider.

Correct Answer is A

Explanation

A. Informing the client that gradual tapering must be used to discontinue the medication is crucial because abruptly stopping antidepressants can lead to withdrawal symptoms or the return of depressive symptoms. This response acknowledges the client’s concerns and provides a safe approach to discontinuation.

B. While side effects may diminish over time for some individuals, this response does not address the client's concerns or provide guidance on how to manage the side effects.
C. Reminding the client that feeling better is the therapeutic effect of the medication does not address the client's concerns about side effects or desire to discontinue the medication.

D. While discussing side effects with the healthcare provider is important, it does not address the need for a safe discontinuation process, which is why gradual tapering should be emphasized first.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse? Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 μmol/L)] Male: [0.6 to 1.2 mg/dL (53 to 106 μmol/L)]

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Exhibits Review H and P and laboratory results. What item(s) should be included in the treatment regimen for this client? Select all that apply.

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

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

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