A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?
"I really wish I had a girl instead."
"I am so relieved the baby looks like my mother."
"My labor was so long I'm glad it's over."
"My appetite has really increased”
The Correct Answer is A
A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.
B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.
C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.
D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Handling cat feces: Toxoplasmosis is most commonly transmitted through exposure to Toxoplasma gondii, a parasite found in cat feces. Handling contaminated litter, soil, or sand without proper hygiene can lead to infection, making this the correct response.
B. Drinking contaminated water: While contaminated water can transmit various infections, toxoplasmosis is primarily associated with exposure to cat feces or undercooked meat, not typically with drinking water.
C. Eating shellfish: Eating shellfish can expose individuals to other types of infections, such as hepatitis A or certain bacterial infections, but it is not a known source of toxoplasmosis.
D. Touching body fluids: Toxoplasmosis is not spread through casual contact with body fluids like saliva, blood, or urine. It is mainly transmitted through ingestion of the parasite from contaminated sources.
Correct Answer is C
Explanation
A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.
B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.
C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.
D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.
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