A client recovering from surgery to place a permanent colostomy ...

[aabwk4]

A client recovering from surgery to place a permanent colostomy as treatment for colon cancer is concerned that her spouse will no longer find her sexually attractive. Which response by the nurse is the most appropriate?
 
  A) Tell me more about the concerns you are having.
  B) Would you like me to speak with your husband for you?
  C) Do not worry about sex right now. It is more important to focus on recovery.
  D) I will refer you to a counselor to talk about your concerns.

Question 2

The nurse is providing care to an older adult Asian-American client diagnosed with respiratory alkalosis. The nurse states to the client, look into my eyes and breathe with me so that we can slow down your breathing rate.
 
  The client continues to look down and refuses to make eye contact with the nurse. The client's daughter later asks you to teach her how to help her mother to control her breathing. When documenting this client's care, which statement is appropriate for the nurse to include?
  A) The client is noncompliant with suggested treatment plan.
  B) The client does not understanding the English language.
  C) The client's culture does not allow for direct eye contact with the nurse during care.
  D) The client's daughter may be abusive.

[bblaney]

Answer to Question 1

Answer: A

Since the client has expressed concern to the nurse regarding sexual functioning, the nurse should ask the client to expand upon why there are concerns. Although a referral may be needed for the client at some point, this is not the most appropriate response by the nurse. Telling the client not to worry about the concern and offering to speak to her spouse are not the most appropriate responses at this time.

Answer to Question 2

Answer: C

A method that is often used to control breathing for client's experiencing hyperventilation is eye contract with the nurse during breathing exercises. It is not uncommon in the Asian culture for eye contact to be deemed as a sign of disrespect. Documenting this finding in the medical record is appropriate. Saying the client is noncompliant is nontherapeutic and labels the client. There is no indication that the client does not speak English. The client's daughter wishes to help her mother control her breathing. This is not indicative of abuse.