A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview, she states, "I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me!" Which of the following responses by the nurse uses empathy?

Correct Answer: C

Rationale: The correct answer is C because it reflects empathy by acknowledging the mother's feelings without judgment or personal bias. The nurse shows understanding and compassion by recognizing the difficulty of the situation. Incorrect answer A lacks empathy as it simply restates the mother's feeling without demonstrating understanding. Answer B also lacks empathy as it focuses on the boyfriend's actions rather than the mother's feelings. Answer D shows some empathy by acknowledging the difficulty but fails to address the mother's emotional state directly. In summary, answer C is correct because it shows empathy by acknowledging the mother's emotions and validating her experience without judgment or redirection.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic hypothesis. Nurses use diagnostic reasoning to formulate diagnostic hypotheses based on patient data and clinical judgment. They analyze symptoms and data to generate potential diagnoses. Choice A, nursing diagnosis, involves identifying patient problems related to nursing care. Choice B, medical diagnosis, is made by physicians to identify diseases or medical conditions. Choice D, diagnostic assessment, refers to the process of collecting and analyzing data to make a diagnosis. Diagnostic hypothesis aligns with the process of diagnostic reasoning in nursing practice.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: C

Rationale: The correct answer is C: at the level of the C7 vertebra. The vertebra prominens refers to the spinous process of the C7 vertebra, which is the most prominent bony landmark at the base of the neck. Assessing this area allows the nurse to accurately locate and evaluate tenderness reported by the physician. Choices A, B, and D are incorrect as they do not correspond to the location of the vertebra prominens. Option A is too high, above the diaphragm; option B is too low, lateral to the knee cap; and option D is too low, at the level of the T11 vertebra.

Correct Answer: C

Rationale: The correct answer is C: Monitor blood pressure. When a client presents with acute abdominal pain, monitoring blood pressure is crucial as it can help assess for potential complications like hypovolemic shock or internal bleeding. Changes in blood pressure may indicate worsening condition and prompt the need for immediate intervention. Monitoring vital signs (A) is important but blood pressure takes precedence in this scenario. Assessing abdominal tenderness (B) is valuable but does not directly address potential life-threatening issues. Monitoring for dehydration (D) is also important but not the most immediate concern in the case of acute abdominal pain.

Correct Answer: B

Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.

Correct Answer: D

Rationale: The correct answer is D because floaters are a common and typically benign phenomenon caused by condensed vitreous fibers in the eye. A nurse should educate the patient that floaters are usually not significant and do not require immediate intervention. Option A is incorrect because counting the number of floaters is unnecessary. Option B is incorrect because presuming glaucoma without proper assessment is inappropriate. Option C is incorrect because seeing occasional floaters is a common and normal occurrence in many individuals.

Correct Answer: B

Rationale: The correct answer is B because reducing alcohol consumption and limiting sodium intake are both crucial lifestyle modifications for managing hypertension. Alcohol can raise blood pressure, while excess sodium can contribute to hypertension. By prioritizing these changes, the patient can better control their blood pressure. Choice A is incorrect because increasing sodium intake can worsen hypertension due to fluid retention. Choice C is incorrect as decreasing physical activity can lead to weight gain and worsen hypertension. Choice D is incorrect as processed foods are often high in sodium and unhealthy fats, which can negatively impact blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.