A client in the clinic states, “I already told you I can’t come back on Friday.” Which response by a nurse would be likely to repair the client-nurse relationship?

“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.

Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.

Choice C. “Never mind about blame.

That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.

It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.

Choice D. “Some people don’t have very good self-control.

We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.

It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.

The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.

This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.

Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.

The surgeon may order interventions based on the assessment findings.

Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.

The nurse should encourage fluid intake only after ensuring adequate urinary output.

Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.

Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.

Normal urine output is about 30 mL per hour or 240 mL in eight hours.

The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.

Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.