An adult client was born as a female gender but has a male gender identity. Which statement by the nurse demonstrates a therapeutic approach of respecting the client's gender identity?
"Do you go by he, she, or they?"
"What pronouns do you go by?""
"What led to this hospital admission?"
"What brings you in today?"
The Correct Answer is B
A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
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Correct Answer is D
Explanation
A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.
B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.
C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.
D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.
Correct Answer is B
Explanation
A. Report the finding so a sleep medication can be prescribed. While this might eventually be necessary, it's premature to suggest medication without further assessing the problem. Other interventions could be tried first.
B. Clarify what the client means by trouble falling asleep. Clarifying the client's statement is essential to understand the specific nature of the sleep problem, such as how long it takes to fall asleep, how often it occurs, and whether there are any contributing factors. This is a critical step in assessment before any further action.
C. Ask the client what they do before going to bed. This is a good follow-up question, but it should come after clarification of what the client means by trouble falling asleep. Understanding pre-bedtime routines is important but secondary to defining the issue.
D. Question the client about their use of caffeine. While this is a relevant question that could affect sleep patterns, it should follow after understanding the client's specific sleep issues.
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