A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

"Have you tried leaving your house just once per day?"

"Have you thought about moving to a new neighborhood?"

"Let's discuss how you feel when you leave your house."

"Tell me why you have developed an aversion to leaving your house."

Answer and Explanation

The Correct Answer is C

Choice A Reason:

"Have you tried leaving your house just once per day?" This response assumes a potential solution without fully understanding the client's feelings. It doesn't encourage open discussion or exploration of the client's anxiety.

Choice B Reason:

"Have you thought about moving to a new neighborhood?" This response jumps to a significant life change as a solution without exploring the client's current situation and emotions. It may not be a practical or necessary step.

Choice C Reason:

"Let's discuss how you feel when you leave your house." This response is an open and therapeutic approach that encourages the client to express their feelings and thoughts about the situation. It allows the nurse to gather more information and better understand the client's anxiety related to leaving the house. The other options do not facilitate open communication or exploration of the client's feelings.

Choice D Reason:

"Tell me why you have developed an aversion to leaving your house." While this response is more open-ended, it phrases the question in a somewhat confrontational manner, which might make the client defensive. The previous response ("Let's discuss how you feel when you leave your house") is gentler and inviting.

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Correct Answer is D

Explanation

Choice A Reason:

Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.

Choice B Reason:

Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.

Choice C Reason:

Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.

Choice D Reason:

Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.

A. "I should do aerobic exercises once per day." B. "I should practice pursed-lip breathing exercises." C. "I will increase my fluid intake to 1,700 milliliters per day." D. "I will consume low-protein, low-calorie foods."

Correct Answer is B

Explanation

Choice A Reason:

"I should do aerobic exercises once per day." While exercise is important for individuals with COPD, the frequency and intensity of exercise should be determined based on the individual's condition and healthcare provider's recommendations. One-size-fits-all recommendations may not apply to all clients.

Choice B Reason:

"I should practice pursed-lip breathing exercises." Pursed-lip breathing exercises are a beneficial technique for individuals with COPD. This technique can help improve breathing efficiency and decrease shortness of breath. Clients with COPD are often taught to use pursed-lip breathing during activities that require increased effort or when experiencing shortness of breath.

Choice C Reason:

"I will increase my fluid intake to 1,700 milliliters per day." While staying adequately hydrated is essential, the specific fluid intake should be determined based on the client's needs, medical condition, and healthcare provider's advice. The recommended daily fluid intake can vary among individuals.

Choice D Reason:

"I will consume low-protein, low-calorie foods." Nutrition is an important aspect of COPD management, but the dietary recommendations should be tailored to the client's specific needs, including their nutritional status, energy expenditure, and other factors. A generalized statement about low-protein, low-calorie foods may not be appropriate for all individuals with COPD.

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A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

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