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 D
Explanation
Choice A: Low-Grade Fever
Low-grade fever is a common early symptom of rheumatoid arthritis (RA). It is often associated with the body’s inflammatory response to the autoimmune activity occurring in the joints. While it can persist throughout the disease, it is not considered a late manifestation.
Choice B: Weight Loss
Weight loss can occur in RA due to chronic inflammation and its effects on metabolism and appetite. However, it is more commonly seen in the early to middle stages of the disease rather than as a late manifestation. Persistent inflammation can lead to muscle wasting and weight loss, but these are not specific to the advanced stages of RA.
Choice C: Anorexia
Anorexia, or loss of appetite, is another symptom that can be present in RA. It is often related to the chronic inflammation and pain associated with the disease, which can reduce a person’s desire to eat. Like weight loss, anorexia can occur at various stages of RA and is not specifically a late manifestation.
Choice D: Knuckle Deformity
Knuckle deformity is a late manifestation of rheumatoid arthritis. As RA progresses, the chronic inflammation can lead to joint damage and deformities, particularly in the hands and fingers. This includes changes such as ulnar deviation, swan neck deformities, and boutonnière deformities. These deformities result from the destruction of joint tissues and the formation of scar tissue, which can significantly impair hand function.
Correct Answer is C
Explanation
Choice A: I’ll Be Sure to Eat More Foods with Vitamin K
This statement indicates a misunderstanding. While vitamin K is essential for blood clotting, consuming large amounts of vitamin K can interfere with the effectiveness of warfarin. Patients on warfarin should maintain a consistent intake of vitamin K to avoid fluctuations in their INR levels.
Choice B: I’ll Take Aspirin for My Headaches
This statement also indicates a misunderstanding. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding when taken with warfarin. Patients should consult their healthcare provider before taking any new medications, including over-the-counter drugs.
Choice C: I’ll Use My Electric Razor for Shaving
This statement indicates an understanding of the teaching. Using an electric razor instead of a traditional blade can help prevent cuts and bleeding, which is particularly important for patients on anticoagulant therapy like warfarin.
Choice D: It’s Okay to Have a Couple of Glasses of Wine with Dinner Each Evening
This statement indicates a misunderstanding. Alcohol can affect the metabolism of warfarin and increase the risk of bleeding. Patients on warfarin should limit their alcohol intake and discuss their drinking habits with their healthcare provider to ensure safe use of the medication.