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Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
- A. Ask the client if she desires an epidural anesthetic.
- B. Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia.
- C. Tell the client that her labor will be more comfortable with an anesthetic.
- D. Ask the client to discuss this with her husband and then make a decision.
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
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You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients?
- A. The client will accept impending death
- B. Guilt related to past transgressions
- C. Spiritual distress related to guilt
- D. Pain related to end of life symptoms
Correct Answer: A
Rationale: Accepting impending death is a common and appropriate goal for hospice clients, as it aligns with the focus of palliative care on achieving peace and closure at the end of life.
A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, 'If only I'd been at home, I could have saved them.' Which of the following responses would be most appropriate?
- A. Don't blame yourself; you'll only feel worse.'
- B. It's not your fault; so stop feeling so guilty.'
- C. You might not have been at home.'
- D. You couldn't have prevented the tornado; it just happened.'
Correct Answer: D
Rationale: Acknowledging the uncontrollable nature of the tornado helps the client process guilt rationally, supporting coping with acute stress disorder.
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.
The nurse is teaching a community group about violence in the family. Which statement by a group member about abusers would indicate a need for further teaching?
- A. They use fear and intimidation.
- B. They usually have poor self-esteem.
- C. They are often jealous or self-centered.
- D. They are more often from low-income families.
Correct Answer: D
Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. The statement that abusers are more common among low-income families is inaccurate. The remaining options do describe characteristics of abusers who often use fear and intimidation to the point where their victims will do anything just to avoid further abuse.