A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?
"Tell me more about how you are feeling about this pregnancy."
"Clients are usually happy about a second pregnancy."
“You will feel better when you have your first ultrasound."
"Let's focus on how you are feeling physically."
The Correct Answer is A
Rationale:
A. "Tell me more about how you are feeling about this pregnancy.": This open-ended, therapeutic statement encourages the adolescent to express her thoughts and emotions. It shows empathy and supports trust-building, which is essential in managing anxiety and promoting emotional well-being.
B. "Clients are usually happy about a second pregnancy.": This response generalizes experiences and dismisses the client’s individual feelings. It may cause the client to feel misunderstood or pressured to conform to others' expectations.
C. "You will feel better when you have your first ultrasound.": This statement minimizes the client’s current emotional state and assumes that reassurance will come from a future event, which may not address the underlying anxiety.
D. "Let's focus on how you are feeling physically.": While physical symptoms are important, this response deflects from the client's expressed emotional concern. It can shut down conversation about her psychological well-being, which is the main issue presented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Subdural hematoma: This condition increases the risk of complications during electroconvulsive therapy (ECT) due to potential elevated intracranial pressure. The seizure activity induced by ECT can further increase pressure and pose a risk of brain herniation or worsening of the hematoma.
B. Renal calculi: Kidney stones may cause pain and hematuria, but they do not directly increase the risk of complications during ECT. Unless there is severe renal impairment or electrolyte imbalance, ECT is generally safe for these clients.
C. Hyperthyroidism: While hyperthyroidism may increase sensitivity to stress or elevate the risk of arrhythmias during procedures, it does not present the same level of direct neurological risk as intracranial pathology like a subdural hematoma.
D. Diabetes mellitus: Diabetes requires careful monitoring during ECT, especially regarding fasting, blood glucose levels, and anesthetic recovery. However, it is not a contraindication and does not present as high a procedural risk as a brain bleed would.
Correct Answer is C
Explanation
Rationale:
A. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.
C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.
D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.
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