A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?
"If I keep gaining weight, I will be miserable."
"I cannot believe I got pregnant. We really weren't even trying to have a baby."
"I understand that hormonal changes can cause me to be happy one minute and sad the next."
"This baby will totally change my lifestyle, and I am not sure I am ready for all of this."
The Correct Answer is C
A. "If I keep gaining weight, I will be miserable." Expressing anxiety about weight gain reflects a lack of emotional readiness and acceptance regarding the physical changes that accompany pregnancy.
B. "I cannot believe I got pregnant. We really weren't even trying to have a baby." Indicating surprise suggests a lack of preparation for the emotional and practical aspects of pregnancy. This reflects that the client may not have fully accepted the reality of the situation.
C. "I understand that hormonal changes can cause me to be happy one minute and sad the next." Recognizing and accepting the emotional fluctuations that can occur during pregnancy due to hormonal changes indicates a level of emotional preparation for the journey ahead.
D. "This baby will totally change my lifestyle, and I am not sure I am ready for all of this." Acknowledging the impact of having a baby on lifestyle is important, but expressing uncertainty suggests that the client may still be struggling with the implications of becoming a parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
A. Sputum characteristics. The presence of blood-tinged sputum raises concern for tuberculosis (TB) or another serious pulmonary condition, requiring further evaluation. Hemoptysis can indicate active infection or cavitary lung disease.
B. Respiratory complaint. The client reports a persistent, productive cough, night sweats, and fatigue, which are hallmark symptoms of TB. These symptoms, combined with recent travel to a TB-endemic region, increase the likelihood of infection and warrant further assessment.
C. Blood pressure. The client’s blood pressure is within the normal range and does not indicate an immediate concern requiring further evaluation.
D. Heart rate. A heart rate of 98/min is elevated but still within an acceptable range for mild illness or fever. While tachycardia can be associated with infection, it is not the most critical finding requiring urgent follow-up.
E. Temperature. A temperature of 38.1°C (100.5°F) indicates a low-grade fever, which is a common sign of TB or other infections. Given the client's symptoms and history, this finding warrants further investigation.
F. Travel history. The client recently traveled to South Africa, a region with a high prevalence of TB. Travel history is a crucial factor in determining TB risk and must be considered in the diagnostic process.
G. Oxygen saturation. The client’s oxygen saturation is 98% on room air, which is within normal limits and does not require further evaluation at this time.
Correct Answer is ["A","B"]
Explanation
A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.
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