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:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
Correct Answer is B
Explanation
A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include? The correct answer is choice B: "You should increase your folic acid intake during your pregnancy.”.
Choice A rationale:
"You should stop taking your prenatal vitamin if you experience nausea.”. This statement is incorrect. Nausea is a common symptom during pregnancy, especially during the first trimester. However, discontinuing prenatal vitamins is not recommended. It's essential to continue taking them to ensure the mother and baby receive adequate nutrients. Prenatal vitamins are designed to provide essential vitamins and minerals that are crucial for the baby's development. Discontinuing them due to nausea could lead to nutrient deficiencies.
Choice C rationale:
"You should limit your iron intake during your first trimester.”. This statement is incorrect. Iron intake should not be limited during the first trimester. Iron is an essential mineral during pregnancy, as the mother's blood volume increases, and iron is required to make more red blood cells to carry oxygen to the baby. Iron deficiency can lead to anemia, which can be harmful to both the mother and the baby. Therefore, iron intake is typically increased during pregnancy to meet the increased demand.
Choice D rationale:
"You should increase your daily calorie intake by 750 calories.”. This statement is not entirely accurate. While it's true that calorie needs increase during pregnancy, the recommended additional calorie intake is generally around 300-500 calories per day, not 750. The exact number can vary from person to person, depending on their pre-pregnancy weight and activity level. Consuming too many extra calories can lead to excessive weight gain, which can have negative consequences for both the mother and the baby. It's important to focus on the quality of calories consumed and ensure they come from nutrient-dense foods.
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