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:
Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia, but it can lead to respiratory depression and toxicity when levels become too high. Administering calcium gluconate helps counteract the effects of magnesium toxicity by competing for binding sites and restoring neuromuscular function. This is the appropriate treatment to address the client's symptoms of respiratory depression, which are suggestive of magnesium sulfate toxicity.
Choice B rationale:
Flumazenil is not the correct choice in this situation. Flumazenil is a medication used to reverse the effects of benzodiazepine overdose, not magnesium sulfate toxicity. It does not have any impact on magnesium levels or their associated toxic effects.
Choice C rationale:
Naloxone is used to reverse the effects of opioids, such as morphine or fentanyl. It is not indicated for magnesium sulfate toxicity. Administering naloxone would not address the client's symptoms or the underlying cause of respiratory depressionzz.
Choice D rationale:
Protamine sulfate is an antidote used to reverse the anticoagulant effects of heparin, not magnesium sulfate. It is not effective in treating magnesium sulfate toxicity. Administering protamine sulfate would not be the appropriate intervention for this situation.
Correct Answer is A
Explanation
A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make? The correct answer is Choice A: "The purpose of this medication is to boost fetal lung maturity.”.
Choice A rationale:
Betamethasone is a corticosteroid given to pregnant women at risk of preterm delivery to accelerate fetal lung maturation. It promotes the production of surfactant in the fetal lungs, which is essential for preventing respiratory distress syndrome in preterm infants. This statement provides accurate information about the medication's purpose.
Choice B rationale:
Stating that the medication is for stopping preterm labor contractions is incorrect. Betamethasone is not a tocolytic agent used to halt contractions. It is solely administered to enhance fetal lung maturity and has no direct effect on uterine contractions.
Choice C rationale:
Indicating that the medication's purpose is to increase the fetal heart rate is inaccurate. Betamethasone does not affect fetal heart rate. Its primary role is to enhance the development of the fetal lungs to improve the newborn's respiratory function.
Choice D rationale:
Mentioning that the medication is to halt cervical dilation is not correct. Betamethasone is not intended to stop cervical dilation or prevent preterm labor. Its primary function is to prepare the fetal lungs for better functioning after birth.
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