A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?
Provide information about alternate birth control methods.
Ask if the client has discussed the decision with their partner.
Emphasize the benefits of having the procedure.
Discuss the client's feelings about the procedure.
The Correct Answer is D
Choice A rationale: Providing information about other birth control methods is appropriate after the nurse explores the client's uncertainty, as it ensures the client's decision-making process is supported by understanding all available options.
Choice B rationale: While involving a partner can be helpful, the nurse’s primary responsibility is to the client’s autonomy; asking this first may shift the focus away from the client’s personal concerns.
Choice C rationale: Emphasizing only the benefits is non-therapeutic and biased. The nurse must remain neutral and allow the client to weigh both the benefits and risks of a permanent procedure.
Choice D rationale: Active listening and exploring the client's feelings are the first steps in the nursing process to address uncertainty. This allows the client to clarify their values and reach an informed decision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Child Protective Services would not be the appropriate agency to refer the guardian of the newborn who requires apnea monitoring at home. Child Protective Services deals with child abuse, neglect, and welfare concerns, which are not related to the specific medical needs of the newborn.
Choice B rationale:
Public Health is the correct choice. Public Health agencies are responsible for promoting and protecting the health of the community. They often provide services such as education, vaccinations, and resources for newborn care. Referring the guardian to Public Health can ensure that they receive appropriate guidance on how to manage the newborn's apnea monitoring needs at home and any other relevant health-related information.
Choice C rationale:
Home Health is not the most suitable agency in this context. Home Health agencies generally provide healthcare services directly in patients' homes, often for individuals who require medical assistance or supervision due to illnesses or post-surgical care. However, for a newborn requiring apnea monitoring, the focus is more on education and support rather than direct medical care.
Choice D rationale:
Women, Infants, and Children (WIC) is not the appropriate agency for referring the guardian of the newborn needing apnea monitoring. WIC is a program that provides supplemental nutrition and support to pregnant women, breastfeeding mothers, and young children. While it is important for the overall health of the newborn, it is not directly related to apnea monitoring or home care.
Correct Answer is B
Explanation
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
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