A nurse in a clinic is caring for a female client who has gonorrhea.
Which of the following actions should the nurse take?

Choice A rationale

Stating that a pelvic exam is a mandatory requirement for birth control pills introduces irrelevant information and potentially pressures the client. While an exam may be recommended, linking it as a prerequisite for medication fails to address the client's expressed anxiety or nervousness directly. The response is dismissive and non-therapeutic, focusing on procedure rather than emotion.

Choice B rationale

While the nurse may be present, promising to stay during the entire exam may not be within the scope of practice or policy, and it prematurely offers reassurance without exploring the client's underlying fears. This response is a barrier to communication, as it shuts down further discussion about the client's specific concerns, which is critical for anxiety reduction.

Choice C rationale

This is the most appropriate therapeutic response, utilizing the open-ended technique of "Tell me more.”. This invites the client to articulate the specific sources of her nervousness, such as fear of pain, embarrassment, or anxiety about potential findings. This client-centered approach facilitates rapport and allows the nurse to provide targeted education and emotional support.

Choice D rationale

Simply telling a client to "relax" is non-therapeutic and minimizes the client's feelings of anxiety. This can increase stress because the client may feel unable to comply with the directive, potentially leading to increased muscle tension and difficulty with the examination. A therapeutic approach focuses on identifying and addressing the source of the nervousness first.

Choice A rationale

Stress incontinence is characterized by the involuntary loss of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or lifting. This condition is typically caused by a weakened pelvic floor musculature or urethral sphincter incompetence, which is distinct from nerve damage following a spinal cord injury.

Choice B rationale

Overflow incontinence involves the involuntary leakage of urine from an overly full bladder that is unable to empty completely, leading to constant dribbling. This is often caused by an obstruction or an underactive detrusor muscle, resulting in large residual urine volumes, which is a potential but not the most specific result of spinal nerve damage.

Choice C rationale

Reflex incontinence is the involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached, without the client sensing the need to void. This is directly caused by a lack of communication and control between the brain and the bladder, a common consequence of upper motor neuron damage following a spinal cord injury.

Choice D rationale

Urge incontinence, or overactive bladder, is the involuntary loss of urine associated with a sudden, strong desire to void (urgency). It is typically caused by involuntary contractions of the detrusor muscle and is generally not the specific type of neurogenic bladder dysfunction directly and primarily associated with a debilitating spinal cord injury.