The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?
"Is there any particular reason why you think this is your fault?"
"With surgery, your baby should have a full recovery."
"This must be a very difficult time for you."
"You did nothing wrong."
The Correct Answer is C
The correct answer is choice C. “This must be a very difficult time for you.”
Choice A rationale:
Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.
Choice B rationale:
While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.
Choice C rationale:
This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.
Choice D rationale:
Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
Correct Answer is D
Explanation
The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.
Choice A rationale:
Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.
Choice B rationale:
Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.
Choice C rationale:
Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.
Choice D rationale:
Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.
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