A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

The correct answer is Choice C: “This must be a very difficult time for you.”

Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors2. Therefore, it’s not something the parent did or didn’t do.

Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.

Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.

Choice D rationale: While it’s true that surgery can help manage the condition1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.

Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.

A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.