A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have a natural childbirth. Which of the following responses should the nurse make?
Maybe next time you can have a vaginal delivery.
It sounds like you are feeling sad that things didn’t go as planned.
At least you know you have a healthy baby.
You can resume sensations sooner than if you had delivered vaginally.
The Correct Answer is B
Choice A reason:
Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.
Choice B reason:
This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.
Choice C reason:
While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.
Choice D reason:
Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.
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Correct Answer is A
Explanation
Choice A reason: 0730:
Regular insulin, also known as short-acting insulin, typically begins to work within 30 minutes after administration. Therefore, ensuring the client receives breakfast at 0730, which is 15 minutes after the insulin dose, aligns with the onset of insulin action. This timing helps to prevent hypoglycemia by ensuring that glucose from the meal is available when the insulin starts to lower blood sugar levels.
Choice B reason: 0745:
Administering breakfast at 0745, which is 30 minutes after the insulin dose, might be slightly delayed. While it is still within the effective window, it is better to have the meal a bit earlier to ensure that glucose is available as soon as the insulin begins to act.
Choice C reason: 0815:
Providing breakfast at 0815, which is an hour after the insulin dose, is too late. By this time, the insulin would have already started to lower blood glucose levels significantly, increasing the risk of hypoglycemia. It is crucial to match the timing of food intake with the insulin action to maintain stable blood sugar levels.
Choice D reason: 0720:
Serving breakfast at 0720, which is only 5 minutes after the insulin dose, is too early. The insulin would not have started to act yet, and the blood glucose levels might rise too high before the insulin begins to lower them. It is important to wait at least 15-30 minutes after administering regular insulin before eating.
Correct Answer is B
Explanation
Choice A: Relapse is an Indication that You Are Not Taking Your Medications Properly
This statement is not entirely accurate. While non-adherence to medication can be a factor in relapse, it is not the only cause. Schizophrenia is a complex condition, and relapses can occur even when medications are taken as prescribed. Stress, changes in routine, and other factors can also contribute to a relapse.
Choice B: You Should Keep Your Provider’s and Therapist’s Number with You
This statement indicates an understanding of the importance of having immediate access to professional help. Keeping contact information for healthcare providers and therapists readily available ensures that the client can quickly reach out for support if they notice early signs of relapse. This proactive approach can help manage symptoms before they escalate.
Choice C: Taking an Additional Dose of Medication is Appropriate as Soon as Signs of Relapse Appear
This statement is incorrect. Clients should not adjust their medication dosage without consulting their healthcare provider. Taking an additional dose can lead to adverse effects and may not address the underlying issue. It is crucial to follow the prescribed treatment plan and seek professional advice if symptoms worsen.
Choice D: You Should Be Aware that Excessive Sleeping is an Early Sign of Relapse
Excessive sleeping is not typically an early sign of schizophrenia relapse. Common early warning signs include insomnia, social withdrawal, difficulty concentrating, and increased paranoia. While changes in sleep patterns can be a symptom, it is more important to recognize the specific signs that have previously indicated a relapse for the individual.