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. Droplet precautions: Droplet precautions are used for infections transmitted by large respiratory droplets, such as influenza or pertussis. Herpes simplex is not spread through respiratory droplets, so droplet precautions are not necessary.
B. Protective environment: A protective environment is designed to protect immunocompromised clients from acquiring infections. It is not used for clients who are infectious, such as those with herpes simplex.
C. Contact precautions: Herpes simplex virus is transmitted via direct contact with lesions or infected bodily fluids. Contact precautions, including wearing gloves and gowns and proper hand hygiene, prevent transmission to healthcare workers and other clients.
D. Airborne precautions: Airborne precautions are reserved for infections transmitted via small droplet nuclei, such as tuberculosis or measles. Herpes simplex does not spread through the airborne route, so these precautions are unnecessary.
Correct Answer is D
Explanation
A. Visual Analog Scale: The visual analog scale requires the child to understand and mark a point on a line representing pain intensity. This scale is appropriate for older children, usually around 7 years and older, and not for an 8-month-old infant.
B. FACES pain scale: The FACES scale uses facial expressions to help children identify pain intensity, but it is suitable for children aged 3 years and older who can understand the concept of choosing a face to represent their pain.
C. Oucher scale: The Oucher scale also relies on the child’s ability to self-report pain by selecting a photograph or numerical representation. It is not appropriate for infants who cannot communicate their pain cognitively.
D. FLACC scale: The FLACC scale assesses pain in infants and young children by observing five criteria: Face, Legs, Activity, Cry, and Consolability. It allows the nurse to evaluate pain objectively in an 8-month-old who cannot verbally self-report.
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