A nurse is caring for a female client who is scheduled to have a pelvic examination.
The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before.”. Which of the following is an appropriate therapeutic response by the nurse?
"Tell me more about your concerns.”.
"All you need to do is relax during the exam.”.
"Don't worry.
"A pelvic exam is required if you want birth control pills.”.
will stay in there with you for the exam.”.
The Correct Answer is A
Choice A rationale:
"Tell me more about your concerns" is an appropriate therapeutic response by the nurse. It encourages the client to express her worries and fears about the pelvic examination. Open-ended questions like this one allow the nurse to better understand the client's specific concerns, which can help in addressing them effectively.
Choice B rationale:
"All you need to do is relax during the exam" may come across as dismissive and may not address the client's anxiety effectively. It's important to acknowledge the client's feelings and offer support rather than making the situation seem overly simplistic.
Choice C rationale:
"Don't worry. I will stay in there with you for the exam" might make the client feel like she has no control over the situation and can be invasive. While offering support is important, it's essential to respect the client's autonomy and provide emotional support through active listening and communication.
Choice D rationale:
"A pelvic exam is required if you want birth control pills" is not an appropriate response to the client's anxiety about the pelvic exam. This response does not address the client's concerns and may not provide the necessary emotional support or information she needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.
Choice B rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.
Choice C rationale:
Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.
Choice D rationale:
Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.
Correct Answer is D
Explanation
The normal sequence of postpartum vaginal discharge, known as lochia, follows this order:
D. Lochia rubra, lochia serosa, lochia alba.
Here's a quick breakdown:
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Lochia rubra (Days 1–4): Bright red discharge with blood, mucus, and tissue.
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Lochia serosa (Days 4–10): Pinkish or brownish discharge as bleeding slows.
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Lochia alba (Days 10–6 weeks): Yellowish-white discharge as the body completes healing.
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