A new mom delivered her baby 2 months ago.
The baby's father calls into the office to report that his wife is angry.
She is confused and having conversations with herself.
What is the appropriate response that the nurse should make?
Please take your wife to the nearest emergency room for evaluation.
Please bring your wife to the office for medication.
Your wife needs outpatient care.
Your wife needs behavioral therapy.
The Correct Answer is A
Choice A rationale:
Advising the caller to take his wife to the nearest emergency room for evaluation is the appropriate response. The new mom's symptoms, including confusion and auditory hallucinations (conversations with herself), are indicative of a serious mental health condition. These symptoms could be caused by postpartum psychosis, a rare but severe form of postpartum depression. Postpartum psychosis requires immediate medical attention and hospitalization for the safety of both the mother and the baby. It is essential to rule out any potential medical causes and provide appropriate psychiatric evaluation and treatment in an emergency setting.
Choice B rationale:
Bringing the wife to the office for medication is not appropriate in this situation. The symptoms described by the baby's father are severe and require urgent evaluation in an emergency room. Medication management should only be initiated after a comprehensive psychiatric evaluation, which can be conducted in an emergency room setting.
Choice C rationale:
Suggesting outpatient care is not appropriate in this case. The severity of the symptoms, including confusion and hallucinations, indicates the need for immediate evaluation in an emergency setting. Outpatient care is not sufficient for addressing acute psychiatric emergencies.
Choice D rationale:
Recommending behavioral therapy is not appropriate for a situation involving acute confusion and hallucinations. Behavioral therapy is a valuable treatment for various mental health conditions, but it is not the appropriate intervention for acute symptoms like those described in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Limiting the time spent on exploration of intimate topics may result in incomplete information, leading to potential gaps in the patient's health history. It's essential to create a safe and supportive environment, allowing the patient to share necessary information freely.
Choice B rationale:
Avoiding questions that may embarrass the patient could prevent the nurse from gathering crucial information related to the patient's reproductive health. Sensitivity and non-judgmental communication are essential, enabling the patient to openly discuss sensitive topics.
Choice C rationale:
Using accepted medical terminology is important, but it should be balanced with clear communication. Complex medical terms might confuse the patient. It's essential to use language that the patient can understand, ensuring effective communication and a better understanding of their health.
Choice D rationale:
This statement indicates a correct understanding of the best approach when obtaining a reproductive health history. Explaining the purpose for the questions asked and how the information will be used builds trust and helps the patient feel more comfortable sharing sensitive information. It also ensures that the patient understands the relevance of the questions, fostering open communication between the patient and the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale:
A stat magnesium sulfate level (Choice A) is unnecessary in this situation. The symptoms described - increased temperature, pulse rate, and blood pressure, along with absent deep tendon reflexes - indicate magnesium sulfate toxicity. Discontinuing the infusion and managing the symptoms take precedence over checking the magnesium sulfate level.
Choice B rationale:
Administering oxygen (Choice B) is important for maintaining the patient's oxygenation levels, but it does not address the magnesium sulfate toxicity. The primary intervention should be to discontinue the infusion and manage the symptoms.
Choice C rationale:
Discontinuing the magnesium sulfate infusion (Choice C) is the correct action in this situation. The symptoms, including absent deep tendon reflexes and the patient's complaint of thirst and warmth, indicate magnesium sulfate toxicity. Stopping the infusion is crucial to prevent further complications.
Choice D rationale:
Hydralazine (Choice D) is an antihypertensive medication and is not the appropriate intervention for magnesium sulfate toxicity. Managing magnesium sulfate toxicity involves discontinuing the infusion and providing supportive care.
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