A gravida 2 para 1 (G2P1) at 38-weeks gestation who is scheduled for a repeat cesarean section in one week is brought to the labor and delivery unit experiencing contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, "I've had 8 children and I know she is in labor.I want her to have her cesarean section right now!" Which action should the nurse take?
Request that the mother leave the room.
Notify the charge nurse of the situation.
Request security to remove her from the room.
Tell the mother to stop speaking for the client.
The Correct Answer is A
A. Request that the mother leave the room: The nurse should prioritize the patient’s needs and comfort, the nurse should calmly request that she leave the room. This allows the nurse to focus on the client’s condition without interference and ensures that the client’s autonomy and wishes are respected.
B. Notify the charge nurse of the situation: While notifying the charge nurse may be appropriate if the situation escalates, the nurse should first try to address the issue directly by requesting that the mother leave the room.
C. Request security to remove her from the room:Security should be a last resort. The situation can likely be handled by the nurse in a calm, respectful manner without the need for security intervention, unless the behavior becomes aggressive or threatening.
D. Tell the mother to stop speaking for the client: This could be perceived as confrontational and disrespectful. It is more effective for the nurse to address the mother’s disruptive behavior by requesting she leave the room so that the client’s privacy and autonomy can be maintained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hydrocortisone: Addison’s disease is characterized by insufficient cortisol production. The client’s symptoms, including weakness, confusion, and dehydration, along with laboratory values indicating low sodium, low glucose, and elevated potassium, suggest an adrenal crisis. Hydrocortisone is the primary.
B. Regular insulin: Regular insulin is used to lower blood glucose levels, but the client’s glucose level is already low, not high. Insulin could worsen the client's hypoglycemia. The focus should be on correcting the cortisol deficiency rather than administering insulin.
C. Broad spectrum antibiotic: While antibiotics may be needed if there’s a concern for infection, there’s no evidence of active infection here. The priority is addressing the client's Addisonian crisis, which is primarily treated with hydrocortisone, not antibiotics.
D. Potassium chloride: The client's potassium is elevated (5.3 mEq/L), but potassium chloride is not indicated in this case. The priority is to manage the underlying adrenal crisis, which will address the electrolyte imbalance.
Correct Answer is B
Explanation
A. "Yoga is not the subject of this group": This response dismisses the client's curiosity and could shut down the conversation. Shutting down the discussion abruptly can make clients feel unheard and discourage participation, hindering the therapeutic environment.
B. "What do you want to know about it?": This response validates the client's interest and encourages open discussion. The nurse can provide a brief explanation without derailing the group session.
C. "Wait, let her finish talking": This response may seem dismissive and could discourage engagement. It is important to address the interruption respectfully while also encouraging dialogue.
D. "Do not interrupt in group again": This kind of response can create a hostile environment, shut down communication, and damage the therapeutic relationship between the nurse and the clients, especially in a mental health setting where trust and open expression are vital.
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