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A client who is in labor has human immunodeficiency virus (HIV) and states to the nurse, 'I know I will have a sick-looking baby.' Which appropriate therapeutic response should the nurse make?
- A. You are very sick, but your baby may not be.'
- B. All babies are beautiful. I am sure your baby will be too.'
- C. You have concerns about how HIV will affect your baby?'
- D. There is no reason to worry. Our neonatal unit offers the latest treatments available.'
Correct Answer: C
Rationale: Option 3 is the most therapeutic response, and it will elicit the best information. It addresses the therapeutic communication technique of paraphrasing. Option 3 also is an open-ended response that will provide an opportunity for the client to verbalize her concerns. Parents need to know that their baby will not look sick from HIV at birth and that there may be a period of uncertainty before it is known whether the baby has acquired the infection. Options 1 and 2 provide false reassurances. The client should not be told that there is no reason to worry.
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Which instruction should the nurse provide to a preschool-age client to prevent altered growth and development?
- A. Trust
- B. Empathy
- C. Impulse control
- D. Problem-solving
Correct Answer: C
Rationale: Teaching a preschool-age child and their parents about the importance of impulse control is essential to prevent the risk of altered growth and development. Preschool-age children are at a stage where they are developing self-regulation skills, so teaching them to manage their impulses can help in their overall growth and development. Trust is a critical concept taught during infancy to foster secure attachments. Empathy is crucial for parents of toddlers to understand their child's emotions. Problem-solving skills are typically emphasized for school-age children to enhance cognitive development.
The client states to the nurse, 'I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?' Which statement by the nurse is the most therapeutic?
- A. Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!'
- B. They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come.'
- C. Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too careful.'
- D. You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?'
Correct Answer: D
Rationale: The client has verbalized concerns. In option 4, the nurse uses reflection to direct the client's feelings and concerns. In option 1 the nurse provides false reassurance and then minimizes the client's concerns. In option 2 the nurse is ventilating the nurse's own anger, frustration, and powerlessness. In addition, the nurse is trying to problem-solve for the client but is overly controlling and takes the decision making out of the client's hands. In option 3, the nurse is projecting the client's own fears, and the problem-solving suggested by the nurse will increase fear and anxiety in the client.
The home health nurse visits a client with a history of type 1 diabetes mellitus. The client has recently experienced permanent loss of vision and is having difficulty adjusting. Which action by the nurse is most appropriate?
- A. Ask the health care provider for a psychiatric referral.
- B. Recommend that the client join a support group.
- C. Warn the client that failure to adapt can increase risk for injury.
- D. Reassure client that a change in visual abilities does not change personal identity.
Correct Answer: D
Rationale: Reassuring the client that vision loss does not alter their personal identity addresses emotional adjustment, fostering hope and self-worth. Support groups are helpful but less immediate, and psychiatric referrals or warnings may not address the client’s current emotional needs.
The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session?
- A. Provide time to explore the client's past.
- B. Demonstrate acceptance of the client and the client's behavior.
- C. Set limits on the client in a nonpunitive manner.
- D. Encourage sublimation of the client's leadership potential.
Correct Answer: C
Rationale: Setting nonpunitive limits ensures a safe group environment, as clients with antisocial personality disorder may manipulate or disrupt. Exploring the past, accepting harmful behavior, or encouraging leadership without boundaries may enable negative behaviors.
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practices?
- A. Spiritual beliefs
- B. Family practices
- C. Emotional factors
- D. Cultural background
Correct Answer: B
Rationale: The correct answer is 'Family practices.' In this scenario, the client's health practices are influenced by the fact that her family members never had annual gynecologic examinations, leading her to believe that such preventive care measures are unnecessary. This highlights the impact of familial behavior on an individual's perception of healthcare. Spiritual beliefs are not the primary factor at play here; they may affect the choice of medical treatment but not the decision to seek preventive care. Emotional factors like stress or fear could influence health practices, but there is no indication of this in the client's case. Cultural background would come into play if the client followed specific health beliefs or customary practices related to illness and health restoration.