A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?
Allow the client to compose herself then change the subject.
"Why don't I come back in a few minutes after you are more composed."
"I'm so sorry that I made you cry. I didn't mean to upset you."
Offer a tissue and sit quietly until the crying subsides.
The Correct Answer is D
A. Allow the client to compose herself then change the subject.
This response allows the client some time to regain composure, which can be helpful. However, abruptly changing the subject may make the client feel dismissed or unheard. It's essential to address the emotional response with sensitivity.
B. "Why don't I come back in a few minutes after you are more composed."
While this response acknowledges the client's emotional state, it may unintentionally communicate a lack of availability or willingness to support the client in that moment. It's important for the nurse to offer support and empathy immediately rather than suggesting a delay.
C. "I'm so sorry that I made you cry. I didn't mean to upset you."
This response acknowledges the client's emotional response and expresses empathy, which is a crucial aspect of providing patient-centered care. However, it's important to avoid taking personal responsibility for the client's emotional reaction, as it may not have been caused solely by the nurse's questions.
D. Offer a tissue and sit quietly until the crying subsides.
This response demonstrates empathy and support by providing a tissue and offering a non-verbal gesture of comfort. Sitting quietly allows the client the space to express her emotions while feeling supported by the nurse's presence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.
B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.
C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.
D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.
Correct Answer is B
Explanation
A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.
B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.
C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.
D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone
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