Nokea
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?
- A. Focusing on the client's physical needs
- B. Encouraging the client to verbalize her feelings about the loss
- C. Reminding the client that she will be able to become pregnant again
- D. Encouraging the client to think of herself, her husband, and their future
Correct Answer: B
Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.
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The nurse is caring for a dying client who states, 'Will you be the executor of my will?' How should the nurse best respond to this client?
- A. I must decline your offer because I am your nurse.
- B. I will carry out your will according to your wishes.
- C. It is an honor to be named the executor of your will.
- D. Tell me more so that I can understand your thinking.
Correct Answer: D
Rationale: The client's question reflects his thoughts about the will and how to obtain an executor, but the question does not reveal why the client is asking the nurse to be executor, and it also does not address other important information. In option 4, the nurse seeks clarification while acknowledging the client's statement. Most agencies do not allow the nurse to be the executor of a client's will (option 3). The other options fail to regard the potential consequences, think critically, or explore the client's motivation and needs.
What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
- A. Scheduling pain medication at regular intervals
- B. Administering the medication only when the pain is severe
- C. Avoiding the administration of medication unless it is requested
- D. Recognizing that less pain medication will be needed by this client compared with other women in labor
Correct Answer: A
Rationale: In a pregnant client with a history of opioid abuse, scheduling pain medication at regular intervals is the initial plan for providing pain relief during labor. This client may have a lower tolerance for pain and a greater need for pain relief. If medication is only administered when the pain is severe, larger doses may be needed, leading to increased anxiety and discomfort. Avoiding medication unless requested is not ideal, as proactive pain management is crucial during labor. Recognizing that less pain medication will be needed by this client compared with others is incorrect, as individuals with a history of opioid abuse often require more medication due to tolerance to addictive drugs.
Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant woman is cared for in her current residence?
- A. Cultural desire
- B. Cultural awareness
- C. Cultural knowledge
- D. Cultural encounters
Correct Answer: A
Rationale: The correct answer is 'Cultural desire.' Cultural desire involves the nurse's motivation and commitment toward caring for individuals from diverse backgrounds. In this scenario, motivating the immigrant to accept differences in prenatal care reflects the nurse's genuine interest in providing culturally competent care. Cultural awareness involves self-examination of one's beliefs and biases. Cultural knowledge refers to understanding various cultural practices and beliefs. Cultural encounters focus on interactions across cultures to enhance communication and mutual understanding. Therefore, in this context, the nurse's actions align more closely with the concept of cultural desire.
When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?
- A. Increase in pulse rate
- B. Widened pulse pressure
- C. Increase in body temperature
- D. Decrease in diastolic blood pressure
Correct Answer: B
Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.
A client with schizophrenia is admitted to the inpatient mental health unit. When asked her name, she responds, 'I am Elizabeth, the Queen of England.' Which should the nurse recognize this client's statement is indicating?
- A. Visual illusion
- B. Loose association
- C. Grandiose delusion
- D. Auditory hallucination
Correct Answer: C
Rationale: A delusion is an important personal belief that is almost certainly not true and that resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. Loose association is thinking that is characterized by speech in which ideas that are unrelated shift from one subject to another. A hallucination is a false perception.