A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make?
"You seem scared to talk to your parents."
"If you want me to, I can tell your parents for you."
"Your parents will have to be told why you are being admitted."
"Give your parents a chance; they'll understand."
The Correct Answer is A
Choice A: "You seem scared to talk to your parents." This response is appropriate because it reflects the client's feelings and shows empathy and respect. It also opens the door for further communication and support from the nurse.
Choice B: "If you want me to, I can tell your parents for you." This response is not appropriate because it does not respect the client's autonomy and confidentiality. It also may make the client feel more anxious or helpless and may damage the trust between the client and the nurse.
Choice C: "Your parents will have to be told why you are being admitted." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound harsh or threatening to the client, who may fear the consequences of telling her parents.
Choice D: "Give your parents a chance; they'll understand." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may have valid reasons to doubt her parents' reaction or acceptance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
- To find out how many gtt/min to set for a manual IV infusion, we need to use this formula: gtt/min = (mL/hr x drop factor) / 60
- In this formula, mL/hr is the rate of infusion in milliliters per hour, drop factor is the number of drops per milliliter for a specific IV tubing, and 60 is the number of minutes in an hour.
- We plug in the given values into this formula: gtt/min = (120 mL/hr x 10 gtt/mL) / 60
- We simplify and solve this equation: gtt/min = (1200 gtt/hr) / 60
- We divide both sides by 60: gtt/min = 20 gtt/hr
- We round off to the nearest whole number: gtt/min = **20**
- We add a leading zero if needed: gtt/min = **20**
- We do not add a trailing zero: gtt/min = **20**
Correct Answer is B
Explanation
Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.
Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.
Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.
Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.
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