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A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

A.

"How are things going at your job?"

B.

"Why do you think this is happening to you?"

C.

"You must he feeling very frightened right now."

D.

"Maybe you should think more positively."

Answer and Explanation

The Correct Answer is C

A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.


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Related Questions

Correct Answer is B

Explanation

A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

  • Initiate an IV infusion of lactated Ringer's
  • Place the client in a left lateral position
  • Maintain continuous monitoring of the FHR

Contraindicated Intervention:

  • Monitor blood pressure every hour

Rationale:

  • Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
  • Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
  • Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
  • Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

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