A nurse is interacting with a client who is a victim of intimate partner violence (IPV). The client reports feeling unable to leave the relationship because of the children. The nurse responds by saying, "I know this must be very difficult for you." Which type of therapeutic communication is the nurse providing?

Open-ended question.

Clarification.

Empathizing.

Paraphrasing.

Answer and Explanation

The Correct Answer is C

A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.

B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.

C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.

D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.

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Correct Answer is C

Explanation

A. Firm, larger, and very tender to touch. This option describes the characteristics of engorged breasts, which typically occur a few days after birth as milk production increases and the breasts become full. Engorged breasts can feel firm, swollen, and tender to the touch due to the increased blood flow and milk accumulation. However, on the first postpartum day, engorgement may not yet be fully developed.

B. Soft, with no change from before delivery. This option is unlikely as the breasts typically undergo changes during the postpartum period, especially with the initiation of lactation. Soft breasts with no change from before delivery would not be expected on the first postpartum day.

C. Filling and secreting colostrum. This option is the most likely finding on the first postpartum day. Colostrum, the early milk produced by the breasts, begins to be secreted during the late stages of pregnancy and continues after birth. On the first postpartum day, the breasts may be filling with colostrum, which is typically thicker and more concentrated than mature breast milk. It is produced in small amounts, about 40-50ml on the first day but that is all an infant normally needs at this time.

D. Slightly firm with immediate let-down response. While some firmness may be present due to the initiation of lactation, an immediate let-down response is less likely on the first postpartum day. The let-down reflex, which triggers the release of milk from the breast, may take some time to establish and may not occur immediately after delivery.

A. Suggest that the parent read aloud to the child at bedtime. B. Discuss with the parent the need for a hearing screening. C. Recommend that the parent enroll the child in preschool. D. Encourage parent to tell the child to ask for what he wants.

Correct Answer is B

Explanation

A. Suggest that the parent read aloud to the child at bedtime. Reading aloud to the child is a beneficial practice that can enhance language development, vocabulary, and communication skills. It provides the child with exposure to language in a meaningful context and can stimulate spontaneous speech.

B. Discuss with the parent the need for a hearing screening. A hearing screening is a prudent intervention as hearing issues can significantly impact speech development. Ensuring the child has normal hearing is a critical first step in addressing delayed speech. Once hearing issues are ruled out, reading aloud and other strategies can be more effectively implemented.

C. Recommend that the parent enroll the child in preschool. Enrolling the child in preschool can provide a language-rich environment and opportunities for social interaction, which can stimulate speech and language development. However, this may not be the first step without ruling out other issues like hearing problems.

D. Encourage the parent to tell the child to ask for what he wants. Encouraging the child to use words to express needs is helpful for language development. It promotes verbal communication and helps the child learn to articulate desires and needs. This strategy, combined with other interventions, can be effective.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

Correct Answer is C

Explanation

During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

Parents bring their 8-month-old child to the clinic because they are concerned that the child is not developing as an older sibling did. Which developmental characteristic should the nurse expect an 8-month-old to exhibit?

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?