Which response would the nurse provide to a client in labor at 32 weeks' gestation who tells the nurse that she and her husband are very concerned because the baby will be born 2 months early?

Correct Answer: B

Rationale: The correct answer is B: ''If you're concerned, let's talk about it.'' Offering to talk with the client encourages her to verbalize concerns, serving as an outlet for tension. The nurse's first step should be to listen to the client's concerns and emotions before providing more specific information. Choice A is incorrect as telling the client she should be concerned reinforces fears and conveys sympathy rather than empathy. Choice C is incorrect because telling the client not to worry and just concentrate on labor denies the client's feelings and cuts off communication. Choice D is incorrect as telling the client not to worry because care has improved denies the client's feelings and provides false reassurance.

Correct Answer: D

Rationale: The transtheoretical model of change defines changing patterns in individuals across five stages based on their readiness to change. The stages are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client acknowledges the benefits of change and considers making the change within the next 6 months. This aligns with the client's realization of the harmful effects of alcohol consumption and intent to stop drinking within 6 months. The action stage involves actively making changes, the preparation stage includes goal-setting with an intention to change within 60 days, and the maintenance stage focuses on sustaining changed behavior for at least 6 months and taking preventive measures to avoid relapse. Therefore, in this scenario, the client's behavior aligns with the contemplation stage of the transtheoretical model of change.

Correct Answer: B

Rationale: When a client receiving a packed red blood cell transfusion experiences tingling in the fingers and headache, these symptoms may indicate an adverse reaction to the transfusion. The nurse's priority action is to immediately stop the transfusion and initiate a normal saline infusion at a keep vein open (KVO) rate. This helps maintain the client's vein patency while addressing the adverse reactions. After stopping the transfusion and initiating the saline infusion, the nurse should assess the client, including vital signs evaluation. Subsequently, the healthcare provider should be notified. Calling the healthcare provider is important, but it should be done after the immediate action of stopping the transfusion. Slowing the infusion rate is not appropriate during a suspected transfusion reaction as it can exacerbate the adverse effects. Assessing the IV site for infiltration is a routine nursing intervention and is not the priority when managing a potential adverse reaction to a blood transfusion.

Correct Answer: A

Rationale: The therapeutic communication technique used in this scenario is reflection. By repeating the client's concern, the nurse acknowledges the client's feelings and encourages further exploration of the topic. Choice A is correct as it reflects the client's worry without offering false assurance, advice, or using professional jargon. Choice B dismisses the client's concerns with false reassurance. Choice C introduces professional jargon, which may hinder effective communication. Choice D provides advice, which can limit the client's expression of feelings and concerns.

Correct Answer: B

Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.