A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider's office for a follow-up visit. On
... [Show More] assessment, the client tells
the nurse that he is feeling depressed. Which response by the nurse is therapeutic?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." ----
CORRECT ANSWER------"Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it
does not encourage the expression of feelings. "Every client who has this
surgery feels the same way for about a month" is a generalization that avoids the
client's feelings.
A nurse is caring for a client who sustained a missed abortion during the second
trimester of pregnancy. For which finding indicating the need for further evaluation does
the nurse monitor the client?
Spontaneous bruising
Decrease in uterine size
Urine output of 30 mL/hr
Brownish vaginal discharge ----CORRECT ANSWER------Spontaneous bruising
Rationale: A major complication of a missed abortion is disseminated
intravascular coagulation (DIC). Bleeding at the sites of intravenous needle
insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may
be early indicators of DIC; they should be reported and require further evaluation.
Missed abortion is the term used to describe when a fetus dies during the first
half of pregnancy but is retained in the uterus. When the fetus dies, the early
signs/symptoms of pregnancy (e.g., nausea, breast tenderness, urinary
frequency) disappear. The uterus stops growing and begins to shrink. Red or
brownish vaginal bleeding may or may not occur. [Show Less]