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 B
Explanation
Rationale:
A. "This helps to keep you hydrated.": Flushing an intermittent infusion device does not hydrate the client, as the small amount of saline used is not intended for fluid replacement. Hydration is achieved through continuous or scheduled fluid administration, not flushes.
B. "This clears blood from the tubing and the catheter.": Flushing helps maintain catheter patency by preventing blood from clotting inside the lumen. It ensures the device remains functional and ready for medication administration when needed.
C. "This makes sure it stays sterile.": Flushing does not sterilize the device. Sterility is maintained through proper handling and use of aseptic technique. The purpose of flushing is mechanical, not antimicrobial.
D. "This prevents leakage of fluid and medication.": While flushing may help confirm that the device is intact, the primary reason is not to prevent leakage but to maintain patency and ensure the catheter is free of occlusions.
Correct Answer is B
Explanation
Rationale:
A. Troponin level: Troponin is a cardiac biomarker used to detect myocardial injury or infarction. It is not an indicator of nutritional status and does not reflect protein levels or nutrient balance.
B. Serum albumin: Albumin is a plasma protein synthesized in the liver and commonly used as a marker of long-term nutritional status. Low levels may suggest protein-energy malnutrition or chronic illness affecting nutrient absorption or intake.
C. Erythrocyte sedimentation rate: ESR is a nonspecific marker of inflammation or infection. While chronic disease can indirectly affect nutrition, ESR does not directly assess nutrient levels or dietary sufficiency.
D. Serum sodium: Sodium levels reflect fluid balance and electrolyte status but are not indicators of nutritional status. They may be influenced by hydration, renal function, or hormonal imbalances, not by dietary protein intake.
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