A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die."
Which of the following responses should the nurse make?
"I'm sure your family does not want you to die."
"Why would you believe such things?"
"How does this make you feel?"
"You should talk to your family about your feelings."
The Correct Answer is C
"How does this make you feel?"
- A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
- B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
- C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
- D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Correct Answer is B
Explanation
Choice A rationale:
Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.
Choice B rationale:
Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.
Choice C rationale:
Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.
Choice D rationale:
Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise, our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.