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 A
Explanation
Choice A: Encourage her to turn, cough, and deep breathe at frequent intervals. This intervention is appropriate for the nurse to include in the client's plan of care at this time because it can help prevent respiratory complications such as atelectasis (collapse of lung tissue) or pneumonia after surgery. Turning, coughing, and deep breathing can help expand the lungs, clear the airways, and improve oxygenation.
Choice B: Ask the client how she feels about having her breast removed. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it may be too intrusive or insensitive. Asking the client how she feels about having her breast removed may trigger emotional distress or anxiety in the client who has just undergone a major surgery that affects her body image and self-esteem. The nurse should wait until the client is more stable and ready to talk about her feelings and concerns.
Choice C: Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Attaching a sign above her bed to have BP, IV lines, and lab work in her right arm may cause injury or infection to the arm that has undergone surgery and lymph node removal. The nurse should attach a sign above her bed to have BP, IV lines, and lab work in her left arm instead.
Choice D: Position her right arm below heart level. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Positioning her right arm below heart level may impair the blood circulation and lymphatic drainage of the arm that has undergone surgery and lymph node removal. The nurse should position her right arm above heart level instead.
Correct Answer is C
Explanation
Choice A: "Store your condoms in your wallet so they are ready for use." This statement is not correct and should not be included in the teaching plan. Storing condoms in a wallet can damage them by exposing them to heat, friction, or puncture. Damaged condoms can break or leak during sexual activity and increase the risk of STIs or pregnancy.
Choice B: "Use petroleum jelly with a latex condom for extra lubrication." This statement is not correct and should not be included in the teaching plan. Using petroleum jelly or any oil-based lubricant with a latex condom can weaken the latex material and cause it to break or slip off. Only water-based or silicone-based lubricants should be used with latex condoms.
Choice C: "Put the condom on before engaging in any genital contact." This statement is correct and should be included in the teaching plan. Putting the condom on before engaging in any genital contact can prevent the transmission of STIs or pregnancy by avoiding contact with pre-ejaculate fluid, semen, or vaginal fluid.
Choice D: "You can reuse a condom if it's within 3 hours." This statement is not correct and should not be included in the teaching plan. Reusing a condom can increase the risk of STIs or pregnancy by exposing the partner to residual fluid, bacteria, or sperm. A new condom should be used for each sexual act.
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