A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

"I know that I will be reunited with my child someday."

"I am unable to feel any joy since my child died."

"I feel guilty because my child died."

"I am angry that my child died."

Answer and Explanation

The Correct Answer is B

A. Belief in being reunited with the child is a common and healthy coping mechanism.

B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.

C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.

D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.

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Correct Answer is ["A","B","C","E","F"]

Explanation

A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.

B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.

C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.

D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.

E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.

F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.

A. Noting changes in the treatment plan in the client's medical record B. Having interdisciplinary team meetings for the client on a regular basis C. Recording the client's progress in the nurses' notes D. Posting swallowing precautions at the head of the client's bed E. None F. None

Correct Answer is B

Explanation

A. While noting changes in the medical record is important, it doesn’t specifically address communication between staff members.

B. Having interdisciplinary team meetings on a regular basis ensures that all healthcare providers involved in the client’s care are informed of the current treatment plan, goals, and changes. This promotes communication and collaboration across disciplines, which is especially important in the care of clients with conditions like expressive aphasia.

C. Recording progress in the nurses’ notes is important, but it alone does not foster active communication between different team members.

D. Posting swallowing precautions is important for the safety of the client but doesn’t address the need for better communication among the team.

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A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor. Exhibits Select the 5 actions the nurse should take.

Correct Answer is ["A","B","C","E","F"]

Explanation

Correct Answer is B

Explanation

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