Nokea
A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, 'After I have this surgery I know my husband will never come near me again.' Which response would the nurse give?
- A. You're underestimating how your husband will respond to your surgery.
- B. You're concerned about the effect on your sexual relations.
- C. You're worried that the surgery will change how others see you.
- D. You're concerned about how your husband will respond to your surgery.
Correct Answer: D
Rationale: The correct response acknowledges the client's expressed concern about her husband's reaction to the surgery, encouraging further discussion without imposing the nurse's assumptions. Choice A reframes the client's concern to focus on the husband's response, aligning more closely with the client's stated worry. Choice B makes an assumption about the client's concerns regarding sexual relations, which may not be the primary focus of her statement. Choice C shifts the attention to how others perceive the client, deviating from the client's specific reference to her husband's reaction, thus not addressing the client's main concern.
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A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?
- A. I'm sorry to hear that.'
- B. Oh, you have a lot of good years left.'
- C. You are concerned about your sex life?'
- D. Have you asked your primary health care provider about that?'
Correct Answer: C
Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I'm sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.
After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?
- A. This must be very difficult for you with this added pressure.''
- B. Having a child is a decision you should make without your parents' input.''
- C. You're lucky. It's nice that your parents are making such a generous offer.''
- D. Five years without a pregnancy is a long time. You were right to come to the fertility clinic.''
Correct Answer: A
Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.
The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?
- A. Asking the mother to change her baby's diaper
- B. Assuring the mother that her baby is receiving excellent care
- C. Encouraging the mother to touch her baby whenever possible
- D. Keeping the mother informed about the care the nursing staff is providing her baby
Correct Answer: C
Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.
A daughter of a Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter's behavior reflect?
- A. Prejudice
- B. Stereotyping
- C. Assimilation
- D. Ethnocentrism
Correct Answer: C
Rationale: The correct answer is assimilation. Assimilation involves incorporating the behaviors of a dominant culture. In this scenario, maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike, which is not demonstrated by the daughter's behavior. Ethnocentrism is the perception that one's beliefs are superior to those of others, which is not evident in this situation.
Why is it important for the nurse to inform the family about the client's situation?
- A. To decrease the client's anxiety
- B. To help the family better adapt to necessary role changes
- C. To improve communication between family and nursing staff
- D. To ensure a more relaxed atmosphere for the client
Correct Answer: B
Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.