A nurse is caring for a female client who is scheduled to have a pelvic examination.
The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before.”. Which of the following is an appropriate therapeutic response by the nurse?
"Tell me more about your concerns.”.
"All you need to do is relax during the exam.”.
"Don't worry.
"A pelvic exam is required if you want birth control pills.”.
will stay in there with you for the exam.”.
The Correct Answer is A
Choice A rationale:
"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.
Choice B rationale:
"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.
Choice C rationale:
"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.
Choice D rationale:
"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Maternal hypertension is the most common risk factor for placental abruption. Placental abruption is a serious condition where the placenta partially or completely separates from the uterine wall before the baby is born. This separation can lead to significant bleeding, which is a medical emergency. Hypertension, also known as high blood pressure, can cause damage to the blood vessels in the placenta, making it more likely for placental abruption to occur. High blood pressure can lead to decreased blood flow to the placenta, increasing the risk of separation.
Choice B rationale:
Maternal battering, while a concerning issue during pregnancy, is not the most common risk factor for placental abruption. Placental abruption is primarily associated with maternal medical conditions and factors that affect the uterine environment.
Choice C rationale:
Maternal cigarette smoking can have adverse effects on pregnancy, but it is not the most common risk factor for placental abruption. Smoking is more commonly associated with other complications such as low birth weight and preterm birth.
Choice D rationale:
Maternal cocaine use is a risk factor for placental abruption, but it is not the most common one. Cocaine can constrict blood vessels and reduce blood flow to the placenta, increasing the risk of abruption. However, hypertension remains the most prevalent risk factor.
Correct Answer is B
Explanation
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
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