# Situation: A 55-year-old woman is scheduled for an elective open cholecystectomy in 4 weeks. At the preoperative clinic visit, she reports smoking 10 cigarettes a day for 20 years. She has type 2 diabetes controlled with metformin. She works as a bookkeeper and says she learns best by doing. While the nurse teaches deep breathing and splinted coughing, she keeps asking, "What if I don't wake up from the anesthesia?" and cannot repeat the first step she was shown. Which action should the nurse take FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629848  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 55-year-old woman is scheduled for an elective open cholecystectomy in 4 weeks. At the preoperative clinic visit, she reports smoking 10 cigarettes a day for 20 years. She has type 2 diabetes controlled with metformin. She works as a bookkeeper and says she learns best by doing.

While the nurse teaches deep breathing and splinted coughing, she keeps asking, "What if I don't wake up from the anesthesia?" and cannot repeat the first step she was shown. Which action should the nurse take FIRST?

## 보기

1. Repeat the breathing steps more slowly with a demonstration
2. Explore her fears about the anesthesia before going on **✔ 정답**
3. Give her a picture leaflet of the exercises to practice at home
4. Arrange for the anesthesiologist to see her before surgery

**정답: 2**

## 해설

High anxiety narrows attention and blocks learning, so the nurse first explores her specific fear with open-ended questions before continuing. Once the fear is addressed, demonstration and practice can succeed. A referral to the anesthesiologist and printed material are useful later but do not come before understanding what she is afraid of.

## 심화 해설

Clinical context

A patient scheduled for elective surgery is showing classic signs of high preoperative anxiety. She repeatedly asks about not waking from anesthesia and cannot recall the first step of a breathing exercise she was just shown. This is not a problem of intelligence, motivation, or teaching method. It is a problem of readiness to learn.

Why anxiety blocks learning

Adult learning depends on three conditions: the learner must be ready, able, and in need of the information [1]. When anxiety is high, the sympathetic nervous system dominates and attention narrows to the perceived threat. In this patient, the threat is anesthesia and the possibility of not waking. While her attention is fixed on that fear, she cannot encode new procedural information such as deep breathing or splinted coughing. The inability to repeat the first step is a behavioral marker that her working memory is occupied by fear, not a sign that the demonstration was too fast or too complex.

Anxiety narrows attention and blocks learning, so the nurse must address the emotional barrier before attempting further teaching. Repeating the demonstration, giving a leaflet, or arranging an anesthesiology consult all assume the patient is ready to learn. She is not yet ready.

Why exploring fear comes first

The correct first action is to explore her specific fear with open-ended questions. This aligns with the principle that assessment of readiness precedes teaching [1]. Asking “What worries you most about the anesthesia?” or “What have you heard or experienced before that makes you afraid?” helps the nurse understand the source of the anxiety. The fear may be based on a previous bad experience, a family member’s complication, or a misunderstanding about anesthesia risk. Until that specific fear is named and acknowledged, the patient’s cognitive capacity for learning remains limited.

Key point! The patient’s repeated question is not a request for more information about anesthesia. It is an expression of fear. The nurse responds to the emotion first, not the content.

Why the other options are not first

Repeating the steps more slowly with demonstration addresses the teaching method, but the method is not the problem. The patient’s attention is unavailable, so a slower demonstration will also fail to be retained. A picture leaflet is a useful supplementary tool for home practice, but written materials are most effective after the learner is engaged and ready [1]. Arranging for the anesthesiologist to see her is appropriate later if the fear persists or if specific medical reassurance is needed, but it does not replace the nurse’s immediate role in exploring the fear at the bedside.

How this fits the nursing process

This situation is an application of assessment before intervention. The nurse has already gathered objective data: the patient cannot repeat a taught step. The next step is to assess the underlying cause of that learning block. Exploring the fear is a focused assessment that will guide the subsequent teaching plan. Once the fear is addressed, the nurse can return to demonstration and practice, and the patient will be more likely to retain the breathing and coughing techniques needed for postoperative recovery.

Effective preoperative teaching is sequenced: assess readiness, address emotional barriers, then teach and practice. Skipping to teaching tools or referrals without addressing readiness violates the basic principle of adult learning [1].

Clinical application

In a preoperative clinic, time is limited, and there is pressure to complete all teaching in one visit. However, spending a few minutes exploring fear can save time later because the patient will learn the exercises correctly the first time. The nurse can say, “It sounds like the anesthesia is really frightening for you. Tell me more about what you are thinking.” This open-ended approach invites the patient to verbalize the specific fear, which often reduces its intensity enough to allow learning to proceed.

Watch out! Do not interpret the patient’s inability to repeat the steps as a cognitive deficit or noncompliance. In a 55-year-old bookkeeper with no reported cognitive impairment, the more likely cause is anxiety-related attention narrowing. The nurse should rule out emotional barriers before considering other explanations.

The first action is to explore the fear, because learning cannot occur while the patient’s attention is consumed by anxiety about anesthesia. This conclusion is consistent with the principle that assessment of the learner’s readiness is the starting point of effective patient education [1].References (research sources)

- [1]Teaching the adult ostomy patient.Research articleO'Shea HS (2001) · DOI: 10.1067/mjw.2001.112085

## 임상 시나리오

Preoperative Teaching ReadinessAddress fear before reteaching
When a patient cannot repeat a step just shown and repeatedly asks about not waking from anesthesia, the priority is to explore the fear with open-ended questions. High anxiety narrows attention and blocks learning.

Adult learning requires readiness, ability, and need. Repeating demonstrations, giving leaflets, or consulting the anesthesiologist are useful only after the emotional barrier is addressed.

CautionDo not mistake the inability to recall steps for a teaching method problem. The patient's working memory is occupied by fear, so reteaching before exploring the fear will fail.

## 핵심 개념

- **Readiness to learn** — The learner's emotional and cognitive state that allows new information to be encoded; high anxiety blocks readiness by narrowing attention to perceived threats.
- **Preoperative anxiety** — Fear or worry before surgery that can impair concentration, memory, and the ability to follow preoperative teaching.
- **Open-ended questions** — Questions that invite the patient to express feelings and concerns in their own words, used to assess emotional barriers before teaching.
- **Splinted coughing** — A postoperative technique where the patient supports the incision with a pillow or hands while coughing to reduce pain and protect the wound.
- **Working memory** — The cognitive system that temporarily holds and processes information; occupied by fear, it cannot effectively encode new procedural steps.

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