Exhibits
Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.
"I can learn to manage my thoughts better through therapy."
"This diagnosis means that I am crazy."
"Many people have the same response to a stressful situation as I am having right now."
"I can use holistic approaches like meditation to help my symptoms."
"I will probably need to be on medication for the rest of my life."
"I am at high risk for post-traumatic stress disorder because I have acute stress disorder."
Correct Answer : B,E,F
B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Using water with 5% dextrose (DW) is appropriate for irrigating certain types of catheters, especially those that require a non-saline solution to maintain patency. However, the choice of irrigation solution should be based on the specific type of catheter and the facility's policies. It does not directly address the immediate issue of the luer-lock syringe.
B. Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.
C. Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.
D. Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
Correct choices;
Gravida 5, para 5 (G5P5)
This means the client has been pregnant 5 times and has given birth 5 times. Multiparity (having had multiple pregnancies and deliveries) is a risk factor for PPH due to uterine overdistension, which can lead to poor uterine tone and difficulty in contracting effectively after delivery.
Delivery of a 9 lb 1 oz (4.1 kg) baby
Larger babies are associated with an increased risk of PPH. The weight of the baby suggests a potentially larger placental surface area and increased uterine distension during pregnancy, which can contribute to uterine atony post-delivery.
Labor for 25 hours
Prolonged labor can lead to uterine exhaustion, where the uterus may not contract effectively after delivery, predisposing the client to PPH.
Forceps-assisted delivery
Instrumental deliveries, including forceps, can cause trauma to the birth canal, including the cervix, vagina, and perineum, increasing the risk of lacerations and bleeding.
Epidural anesthesia
Epidurals can mask the pain associated with uterine atony, which may delay the diagnosis of PPH. It's important to closely monitor uterine tone and blood loss in clients who have had epidurals.
4th degree laceration
Explanation: A 4th degree laceration involves the perineum and extends through the anal sphincter complex. Such extensive trauma increases the risk of significant bleeding postpartum.
Estimated blood loss of 600 mL
Although this is within the normal range of blood loss immediately after delivery, it still signifies that the client has experienced significant hemorrhage, putting her at higher risk for ongoing bleeding.
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