A nurse is caring for a female client scheduled to have a pelvic exam. The client tells the nurse, “I’m really nervous.
I’ve never had a pelvic exam before.” Which of the following is an appropriate therapeutic response by the nurse?
A pelvic exam is required if you want birth control pills
Don't worry, I will stay in there with you for the exam
All you need to do is relax during the exam
Tell me more about your concerns
The Correct Answer is D
Rationale for Choice A:
A pelvic exam is required if you want birth control pills. This response is not therapeutic because it dismisses the client's feelings and does not address her concerns. It focuses on the policy or requirement rather than the client's emotional needs. It could make the client feel like her anxiety is not justified or that she has no choice in the matter.
Rationale for Choice B:
Don't worry, I will stay in there with you for the exam. While this response may be intended to provide reassurance, it does not fully address the client's underlying concerns. It offers a solution without first exploring the specific reasons for the client's anxiety. It could also make the client feel dependent on the nurse's presence for comfort, rather than empowering her to manage her own anxiety.
Rationale for Choice C:
All you need to do is relax during the exam. This response is not therapeutic because it minimizes the client's feelings and suggests that she can simply control her anxiety by relaxing. It does not acknowledge the validity of her concerns or provide any guidance on how to manage those concerns. It could make the client feel like her anxiety is her fault or that she is not coping well.
Rationale for Choice D:
Tell me more about your concerns. This is the most therapeutic response because it encourages the client to express her feelings and concerns openly. It validates the client's experience and demonstrates active listening and empathy. It provides an opportunity for the nurse to gather more information about the specific reasons for the client's anxiety and to tailor interventions accordingly. It also empowers the client by allowing her to share her thoughts and take control of the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A:
An IV is not routinely initiated prior to a non-stress test. It may be started if a biophysical profile (BPP), which includes an ultrasound, is also being performed, or if there is a risk of complications that may necessitate immediate intervention. However, it is not a standard part of the non-stress test itself.
Rationale for Choice B:
Nipple stimulation is not a standard component of a non-stress test. It may be used in some cases to try to induce fetal movement if the fetus is not moving actively enough during the test. However, it is not a routine part of the procedure.
Rationale for Choice C:
An ultrasound is not typically performed prior to a non-stress test. It may be done as part of a BPP, but it is not necessary for the non-stress test itself.
Rationale for Choice D:
An external fetal monitor is essential for conducting a non-stress test. This monitor uses two belts that are placed around the mother's abdomen. One belt measures the fetal heart rate, and the other belt measures uterine contractions. The monitor records the fetal heart rate and any contractions for a period of 20 to 40 minutes. The test is considered reactive (normal) if the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice during the test. This acceleration in heart rate is typically in response to fetal movement.
Correct Answer is D
Explanation
Choice A rationale:
Tachycardia, or a fast heart rate, is not a common finding in severe preeclampsia. While some women with preeclampsia may experience a slight increase in heart rate, it is not typically a significant or defining feature of the condition. In fact, some women with severe preeclampsia may even experience a slightly decreased heart rate due to increased vagal tone.
Choice B rationale:
Hypotension, or low blood pressure, is also not a typical finding in severe preeclampsia. Blood pressure is often elevated in preeclampsia, and it is one of the key diagnostic criteria. Hypotension would be a concerning finding in a woman with preeclampsia, as it could indicate a serious complication such as placental abruption or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
Choice C rationale:
Polyuria, or excessive urination, is not a characteristic finding of severe preeclampsia. In fact, many women with preeclampsia experience oliguria, or decreased urine output, due to decreased kidney function. This is because preeclampsia can cause damage to the blood vessels in the kidneys, impairing their ability to filter blood and produce urine.
Choice D rationale:
Headache is a common and often severe symptom of severe preeclampsia. It is thought to be caused by increased pressure within the brain due to swelling and vasoconstriction of the blood vessels. Headaches in preeclampsia can be very intense and may be accompanied by other symptoms such as blurred vision, nausea, and vomiting. They are often a sign that the preeclampsia is worsening and that delivery may be necessary.
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