The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

hypovolemic shock.

hemodilution.

excess fluid volume.

deficient fluid volume.

Answer and Explanation

The Correct Answer is C

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

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Correct Answer is B

Explanation

A. Provide information about sexual orientation and comment on alternatives: This step involves providing information about sexual orientation and discussing alternatives. However, it may not be the first step in the PLISSIT model. First, the nurse should establish a supportive and nonjudgmental environment, which is addressed in option B.

B. Communicate an open, accepting attitude: This is the correct response. In the PLISSIT model, the first step is to establish an open, accepting attitude. This involves creating a safe space for the client to express their concerns without fear of judgment or discrimination. By demonstrating acceptance and empathy, the nurse encourages the client to feel comfortable discussing sensitive topics related to sexual orientation.

C. Provide a referral for the client to see a sex therapist: Referral to a sex therapist may be appropriate for clients who require specialized intervention beyond the nurse's scope of practice. However, in the PLISSIT model, referral to a specialist typically occurs after the initial steps of establishing rapport and assessing the client's needs.

D. Teach the client about normal sexual health: While education about normal sexual health is an important aspect of sexual health nursing, it may not be the first step in the PLISSIT model. Initially, the focus is on creating a supportive environment and building trust with the client.

A. should be explored while talking to the client. B. should be explored before talking to the client. C. should be shared with the client. D. are not necessary to explore.

Correct Answer is B

Explanation

A. should be explored while talking to the client: While it's important for the nurse to be aware of their own personal values and attitudes regarding sexuality, exploring them while talking to the client may not be the most appropriate approach. The focus during client interaction should be on understanding the client's perspectives, concerns, and needs, rather than discussing the nurse's personal values and attitudes.

B. should be explored before talking to the client: This is the most appropriate action. Before discussing sexuality with a client, the nurse should take time to reflect on their own personal values and attitudes regarding sexuality. This self-awareness can help the nurse approach the discussion with sensitivity, open-mindedness, and professionalism, ensuring that their own biases do not negatively influence the care provided to the client.

C. should be shared with the client: Sharing one's own personal values and attitudes regarding sexuality with the client is generally not recommended. The focus of the interaction should be on the client's needs, concerns, and preferences, rather than the nurse's personal beliefs. Sharing personal values could potentially undermine the therapeutic relationship or make the client feel uncomfortable or judged.

D. are not necessary to explore: Exploring one's own personal values and attitudes regarding sexuality is essential for providing client-centered care and maintaining professionalism. Ignoring or dismissing the nurse's own values can lead to biases influencing the care provided to the client. Therefore, it is necessary for the nurse to explore their own values before engaging in discussions with clients about sexuality.

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The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

Correct Answer is B

Explanation

When assessing a client's sexuality, the nurse is aware that one's own personal values and attitudes:

Correct Answer is B

Explanation

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