A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?
"Tell me more about how you are feeling about this pregnancy."
"Clients are usually happy about a second pregnancy."
“You will feel better when you have your first ultrasound."
"Let's focus on how you are feeling physically."
The Correct Answer is A
Rationale:
A. "Tell me more about how you are feeling about this pregnancy.": This open-ended, therapeutic statement encourages the adolescent to express her thoughts and emotions. It shows empathy and supports trust-building, which is essential in managing anxiety and promoting emotional well-being.
B. "Clients are usually happy about a second pregnancy.": This response generalizes experiences and dismisses the client’s individual feelings. It may cause the client to feel misunderstood or pressured to conform to others' expectations.
C. "You will feel better when you have your first ultrasound.": This statement minimizes the client’s current emotional state and assumes that reassurance will come from a future event, which may not address the underlying anxiety.
D. "Let's focus on how you are feeling physically.": While physical symptoms are important, this response deflects from the client's expressed emotional concern. It can shut down conversation about her psychological well-being, which is the main issue presented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Perform aerobic activities three times per week.": While exercise can be beneficial, excessive aerobic activity may worsen fatigue in clients with MS. Low-impact and well-paced exercise is more appropriate.
B. "Soak in a hot bath.": Heat can exacerbate symptoms in clients with MS by increasing nerve conduction issues, potentially leading to worsening fatigue or vision changes.
C. "Have your partner complete activities of daily living for you.": Encouraging dependence can contribute to decreased function and self-esteem. Clients should be supported to remain as independent as possible within their limits.
D. "Schedule rest periods during the day.": Fatigue is a common symptom of MS. Rest periods help conserve energy and prevent exacerbation of symptoms, promoting better overall functioning.
Correct Answer is D
Explanation
Rationale:
A. Instruct the client to shower and change their clothes: The client should avoid bathing, showering, changing clothes, eating, or drinking before a forensic examination. These actions can destroy vital evidence needed for legal and medical purposes.
B. Ask the client for details about the assault: While the nurse should provide emotional support and allow the client to speak if they choose, probing for details can be retraumatizing. A trained forensic examiner should conduct this interview in a sensitive and structured manner.
C. Reassure the client that their injuries are not life threatening: While reassurance is important, making assumptions about the severity of injuries can invalidate the client’s emotional trauma. The nurse should focus on safety, stabilization, and support.
D. Limit the number of staff members providing care for the client: Reducing the number of caregivers helps minimize overstimulation, preserves privacy, and creates a sense of control and safety for the client. This trauma-informed approach is essential in early post-assault care.
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