Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?
A. Tolerates physical discomforts
B. Is eager to review the birth experience
The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.
C. Begins reconnecting with their partner
D. Performs self-care independently
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B. The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.
Similar Questions
A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?
A. Instruct the family to leave prior to cleaning the client's body.
B. Encourage the family to express their feelings of loss.
The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.
C. Limit the amount of time the family spends in the client's room.
D. Ask the family not to touch the client's body.
Full Explanation
The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.
A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?
A. The client has a decreased energy level.
A decreased energy level can be a common symptom of many conditions, including terminal illnesses. While it can be associated with feelings of hopelessness, it is not necessarily an indication of it. Other factors like the illness itself, treatments, or emotional stress can contribute to low energy.
B. The client requests a second opinion.
Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.
C. The client wants to talk about the diagnosis with the nursing staff.
Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.
D. The client makes funeral arrangements.
When a client makes funeral arrangements, it can be a sign that they are feeling hopeless about their situation and are preparing for the end of their life. While it is practical and sometimes necessary to make such arrangements, in this context, it can be seen as a manifestation of hopelessness.
Full Explanation
A. The client has a decreased energy level. A decreased energy level can be a common symptom of many conditions, including terminal illnesses. While it can be associated with feelings of hopelessness, it is not necessarily an indication of it. Other factors like the illness itself, treatments, or emotional stress can contribute to low energy.
B. The client requests a second opinion. Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.
C. The client wants to talk about the diagnosis with the nursing staff. Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.
D. The client makes funeral arrangements. When a client makes funeral arrangements, it can be a sign that they are feeling hopeless about their situation and are preparing for the end of their life. While it is practical and sometimes necessary to make such arrangements, in this context, it can be seen as a manifestation of hopelessness.
A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?
A. Instruct the client to lie supine with his knees flexed.
This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury.
B. Position the client in semi-Fowler's position.
Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately.
C. Cover the wound with a dry sterile dressing.
Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases.
D. Cover the wound with a transparent dressing.
A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.