Question

the nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. when the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, \get out of here! ill get up when im ready!\ which response is best for the nurse to make?

your healthcare provider has prescribed ambulation on the first postoperative day.
you must ambulate to avoid complications which could cause more discomfort than ambulating.
i know how you feel. youre angry about having to ambulate, but this will help you get well.
ill be back in 30 minutes to help you get out of bed and walk around the room.

Explanation:

Analyze client behavior and developmental needs

The client is an 18-year-old with an intellectual disability exhibiting anger and resistance to postoperative ambulation. This behavior represents a need for control and autonomy over her immediate situation, which is common when facing stressful hospital procedures.

Evaluate communication options

• Option 1 and Option 2 ignore the client's emotional state, offer authoritative demands, and fail to address her need for control.
• Option 3 uses a cliché ("I know how you feel") which is non-therapeutic and dismissive of her unique experience.
• Option 4 respects the client's autonomy and need for control by allowing a brief delay, while maintaining the clinical goal of ambulation by setting a clear, firm expectation to return in 30 minutes.

Select the optimal nursing response

Allowing the client a structured 30-minute period of control de-escalates the anger while ensuring the postoperative care plan (ambulation) is successfully completed shortly thereafter.

Answer:

• (A) Your healthcare provider has prescribed ambulation on the first postoperative day.
• (B) You must ambulate to avoid complications which could cause more discomfort than ambulating.
• (C) I know how you feel. You're angry about having to ambulate, but this will help you get well.
• (D) I'll be back in 30 minutes to help you get out of bed and walk around the room. (Correct answer)