A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, "We've been trying to get pregnant for several months. but now I'm not sure I'm ready." Which of the following responses should the nurse make?
"You need to talk to a therapist about how you're feeling”
"I wouldn't worry about it if I were you. You'll be a good mother.”
"Why do you feel that way if you've been trying to get pregnant?"
"Many women experience feelings of ambivalence during pregnancy."
The Correct Answer is D
A. "You need to talk to a therapist about how you're feeling.": Referring to a therapist may be appropriate later if needed, but this response does not validate the client’s feelings or provide immediate emotional support. It may also make the client feel dismissed.
B. "Wouldn't worry about it if I were you. You'll be a good mother.": This response minimizes the client’s feelings and provides reassurance rather than acknowledging their ambivalence. Minimization can inhibit open communication and does not promote therapeutic rapport.
C. "Why do you feel that way if you've been trying to get pregnant?": Asking "why" can come across as judgmental or confrontational and may make the client defensive. It does not provide support or normalize the experience of mixed emotions.
D. "Many women experience feelings of ambivalence during pregnancy.": This response normalizes the client’s feelings, validating their experience without judgment. It encourages open discussion and helps the client feel understood, which is a key aspect of therapeutic communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. To stay with the client's body for 8 hr following their death: While family presence is important, there is no specific Hindu requirement for remaining with the body for a set number of hours. Practices vary, and extended vigil is not a universal expectation.
B. To bury the client's body within 24 hr of the death: Hindu tradition typically favors cremation rather than burial. Burial within a specific timeframe is not commonly observed in Hindu customs.
C. To cremate the client's body: Cremation is the preferred method of body disposition in Hinduism, as it is believed to release the soul from the physical body and aid in the process of reincarnation. Nurses should anticipate and facilitate cremation requests according to religious customs.
D. To prohibit medical personnel from touching the client's body: While modesty and respect are important, Hindu practices generally do not prohibit caregivers from providing postmortem care. Proper handling with reverence and adherence to rituals is expected rather than a complete prohibition.
Correct Answer is ["A","D","E"]
Explanation
A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.
B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.
C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.
D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.
E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.
F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.
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