Which client statement should alert a nurse that a client may be responding maladaptively to stress?
A) "I've found that a few glasses of wine each evening really helps me unwind."
B) "I really enjoy journaling; it's my private time."
C) "I signed up for a yoga class this week."
D) "I made an appointment to meet with a therapist."
A
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The nurse admits a client in the early stage of labor and asks if the membranes have ruptured. The client states, "I don't know if my water broke or not." The nurse plans to call the physician, who will ask if membranes have ruptured
The nurse will: 1. Quote the mother's response and tell the physician that status of membranes is unknown. 2. Assume membranes are intact, or the client would know they ruptured. 3. Perform a pelvic examination to determine if membranes are intact. 4. Perform a Nitrazine test of vaginal secretions for presence of amniotic fluid.
A nulliparous woman has been admitted to the labor and birth unit. Her Bishop score is 4. What medication does the nurse plan to administer?
A. Betamethasone (Celestone) B. Hydromorphone (Dilaudid) C. Misoprostol (Cytotec) D. Oxytocin (Pitocin)
The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus. Which action is most appropriate by the nurse
A) Withholding food and fluid intake until intestinal motility has returned B) Encouraging the client to increase fluid intake to promote peristalsis C) Encouraging the client to increase solid food intake to promote peristalsis D) Encouraging the client to decrease the amount of oral intake
A nurse makes a home visit to monitor the blood pressure of a pregnant woman who is single. Which finding would be of most concern to the nurse?
a. The bedroom is located on the second floor. b. She has a pet cat. c. There is an area rug in the living room. d. She has a 1-year-old child.