The patient in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best?
1. "Lack of menses and breast enlargement are presumptive signs of pregnancy.".
2. "The changes you are describing are definitely indicators that you are pregnant.".
3. "Lack of menses can be caused by many things. We need to do a pregnancy test.".
4. "You're probably not pregnant, but we can check it out if you like.".
3
Rationale 1: Although a lack of menses and breast enlargement are presumptive signs of pregnancy, the nurse should not state this without explaining that these symptoms also can be caused by weight gain and other conditions.
Rationale 2: This statement is false because amenorrhea and breast enlargement can be caused by other conditions.
Rationale 3: This is a true statement, and addresses that these changes could be caused by things other than pregnancy.
Rationale 4: While lack of menses and breast enlargement might not be caused by pregnancy, they likely are the result of pregnancy, and it is inappropriate for the nurse to suggest the patient is not pregnant.
You might also like to view...
The nurse reviews Accolate and Zyflo, which are _______________ _______________; they are capable of blocking the inflammatory response as well as providing bronchodilation
ANS:
What physical assessment finding is consistent with injury to the rotator cuff?
A. The client is unable to maintain adduction of the affected arm at the shoulder for more than 30 seconds. B. The client is able to raise the affected arm to shoulder height but feels pain on doing this maneuver. C. The client is unable to initiate or maintain abduction of the affected arm at the shoulder. D. The client has referred pain to the shoulder and arm opposite the affected shoul-der.
MC The number of physicians in the United States nationwide is sufficient to meet health care needs, but this number has contributed to escalating health care costs due to
A. Increased numbers of uninsured citizens. B. More expensive prescription medications being prescribed. C. The higher number of specialists than generalists. D. Decreased hospital beds nationwide.
The community health nurse has developed and presents a program on suicide risk factors and warning signs to parents of local high school students. What level of intervention would this program be considered?
A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Reduction intervention