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A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks' gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the primary health care provider will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, 'No, no, you can't go, my little man.' The nurse should recognize the client's behavior as an indication of which psychosocial reaction?
- A. Fear of hospitalization
- B. Fear of loss and the death of the fetus
- C. Grief due to potential loss of the fetus
- D. Cognitive confusion as a result of shock
Correct Answer: C
Rationale: Grief occurs when a client has knowledge of an impending loss, such as when signs of fetal distress accelerate. The first stages of grieving may be characterized by shock; emotional numbness; disbelief; and strong emotions such as tears, screaming, or anger. The remaining options are not focused on the mother's expressed concerns.
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A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea-anxiety-dyspnea cycle?
- A. Guided imagery and limiting fluids
- B. Relaxation and breathing techniques
- C. Biofeedback and coughing techniques
- D. Distraction and increased dietary carbohydrates
Correct Answer: B
Rationale: Relaxation and breathing techniques are effective in interrupting the dyspnea-anxiety-dyspnea cycle by calming the client and improving respiratory efficiency. These techniques help reduce anxiety, which can exacerbate dyspnea, and promote controlled breathing to enhance oxygenation. Guided imagery may be helpful but limiting fluids is unrelated to managing dyspnea or anxiety. Biofeedback and coughing techniques are not primarily indicated for this cycle. Distraction and increased dietary carbohydrates do not directly address the cycle and may not provide immediate relief.
A young female client hospitalized on the inpatient psychiatric unit receives treatment for anorexia nervosa. Which statement made by the client to the nurse best indicates improvement?
- A. The client states, 'I realize I am too thin and that it is not good for me, but I do not know how to eat more without getting fat.'
- B. The client requests a sanitary pad, saying, 'I did not think to bring anything with me. I have not had a period for months.'
- C. The client states, 'Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals.'
- D. The client asks for her discharge date to be delayed and says, 'I do not feel ready yet to deal with the tension in my family and their demands for perfection.'
Correct Answer: C
Rationale: Looking forward to meals indicates improved appetite and a positive shift in attitude toward eating, a key sign of progress in anorexia treatment. Other statements reflect awareness, physical changes, or anxiety, but do not directly indicate improved eating behavior.
The nurse is caring for an 11-year-old child who has been physically abused. Which therapeutic action should the nurse include in the plan of care?
- A. Encouraging the child to confront the abuser
- B. Providing a care environment that fosters trust
- C. Teaching the child to make wise choices when faced with possible abuse
- D. Reinforcing for the child that not all adults are capable of abusing children
Correct Answer: B
Rationale: Providing a safe and trusting environment is critical for a child who has experienced physical abuse, as it helps the child feel secure and supported, facilitating emotional healing. Encouraging the child to confront the abuser is inappropriate and could be traumatic, especially for a young child. Teaching the child to make wise choices in potentially abusive situations places an unrealistic burden on the child, who may not have the capacity to protect themselves. Reinforcing that not all adults are abusive is less immediate and does not directly address the child's need for a safe and trusting care environment.
An older adult client who appears alert, oriented, and well-groomed shares with the nurse, 'Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them.' Which response by the nurse is appropriate?
- A. Has anyone in your family ever been diagnosed with schizophrenia?
- B. What medications have you been taking recently?
- C. Don't worry. You may actually have been asleep and dreaming.
- D. The Alzheimer organization offers some tests you may want to take.
Correct Answer: B
Rationale: Inquiring about medications explores potential causes of hallucinations, such as side effects, which is a common issue in older adults. Schizophrenia or Alzheimer’s assumptions are premature, and dismissing as dreaming ignores the client’s awareness.
The nurse is preparing a client for a parathyroidectomy when the client states, 'I guess I'll have to wear a scarf after this surgery.' Considering this statement, which concern should the nurse address?
- A. Denial that the surgery is necessary
- B. Trouble coping with the need for surgery
- C. Issues with potential changes to body image
- D. Anxiety about postsurgical altered function
Correct Answer: C
Rationale: The client's statement reflects a psychosocial concern regarding his or her appearance after surgery, so option 3 is the correct option. The remaining options identify unsuitable problems that are not supported by the provided client data.