A client presents to the emergency department with a wound that occurred 36 hours ago. The wound is red, hot, and draining a small amount of pus. Which statement by the nurse is indicated?
1. "You should have come in earlier instead of waiting until you got an infection."
2. "This redness, heat, and pus indicate your immune system is trying to fight off an infection."
3. "This is a nasty-looking wound."
4. "Didn't you clean this out when it happened?"
2
Rationale 1: While this is a true statement, it is not therapeutic. A better way to phrase this information would be, "It is better to treat a wound early so it doesn't get infected."
Rationale 2: This statement gives the client information about what is happening without demeaning the client.
Rationale 3: It is not therapeutic to tell the client that a wound is "nasty-looking."
Rationale 4: The client may not understand "cleaning this out," and this statement is accusatory.
You might also like to view...
A student nurse is in her community health clinical rotation. She is visiting a family with a new baby. Which of the following statements made by the mother of a 1-month-old infant indicates the need for client education?
a. "My baby should double his birth weight by the time he is 6 months old." b. "I shouldn't give my baby any cow's milk until he is at least a year old." c. "My baby has been fussy lately; I believe he is probably cutting his teeth." d. "I shouldn't put my baby on a fluffy pillow to sleep."
The nurse is caring for an older patient who has been newly diagnosed with tonic–clonic seizures. About which medication should the nurse prepare to instruct the patient?
1. Diazepam (Valium) 2. Phenytoin (Dilantin) 3. Clonazepam (Klonopin) 4. Valproic acid (Depakene)
The nurse explains that the medically supervised approach to weight reduction will include: (Select all that apply.)
a. medications to suppress the appetite. b. an exercise program. c. participation in a support group. d. stress reduction. e. change in concepts about food.
Which nursing intervention is most appropriate when caring for an infant with a myelomeningocele in the preoperative stage?
1. Placing infant supine to decrease pressure on the sac 2. Appling a heat lamp to facilitate drying and toughening of the sac 3. Measuring head circumference every shift to identify developing hydrocephalus 4. Appling a diaper to prevent contamination of the sac