The NCLEX-RN question bank.

Answer

The key, and why

Read the record first and the advice follows from it. One to three centimeters over four hours, contractions six to eight minutes apart lasting 25 to 35 seconds and recorded as mild: this client is in the latent phase, which is the longest and slowest part of labor and often the part a client spends at home. What helps in the latent phase is ordinary. Eating lightly and drinking keeps her going for a labor that may have many hours left. Moving about and changing position helps the presenting part settle onto the cervix and is more comfortable than lying still. Resting between contractions banks the energy she will need later. The advice that matters is as much about what not to start yet. A client who begins the strong breathing patterns at two centimeters has nothing left by transition, and a client put to bed at the beginning of a long labor loses the one thing that helps it along.

Each distractor

Option A starts the strong breathing patterns. Those are for contractions she cannot talk through, and using them on mild contractions six minutes apart exhausts her before the part of labor that needs them. Option C keeps her in bed for monitoring. Continuous monitoring is not needed in a normal latent phase, and lying still slows labor and increases the pain. Option D suggests an epidural now. Sited this early it can slow a labor that has barely started, and the decision belongs to the client when she wants it rather than to a schedule.

The teaching point

LATENT is 0 to 3 cm. Contractions 5 to 30 min apart, 15 to 30 sec, MILD. It is the LONGEST and SLOWEST phase, and it is often spent AT HOME. Eat LIGHTLY, drink, MOVE ABOUT and REST between contractions. Do not start the strong breathing patterns yet. She will need them later. Lying still in early labor SLOWS it and HURTS more.

Answer

The key, and why

The parathyroid glands are four small glands sitting on the back surface of the thyroid, and they are the glands that control calcium. Taking out the whole thyroid puts them in the surgical field, and they can be bruised, have their blood supply interrupted, or be removed with the specimen. That is why the low calcium of a thyroidectomy arrives on a schedule. It shows up at about 24 to 48 hours rather than in the recovery room, and a nurse who knows the timing is checking for it before the client complains.

Each distractor

Option A confuses the two hormones. Parathyroid hormone controls calcium; thyroid hormone controls metabolism. Option C is not a real effect of anesthesia. Option D is not the mechanism, and a day without food does not drop calcium to the point of tetany.

The teaching point

The PARATHYROIDS sit on the BACK of the THYROID. Four of them. PARATHYROID hormone controls CALCIUM. THYROID hormone controls METABOLISM. The low calcium appears at 24 to 48 HOURS, not immediately. TOTAL thyroidectomy = TETANY risk.

Answer

The key, and why

Grief is the normal emotional response to loss. Two weeks after a death, expecting to see the person, crying and yearning are expected. The nurse's role is to acknowledge the loss and the feelings and to be present, not to fix them. Stating the obvious in an empathic way ("It is hard to lose someone you have loved") is therapeutic. It names the loss, shows understanding and lets the client keep talking about his wife if he wants to.

Each distractor

Option A imposes the nurse's beliefs and offers a comfort the client may not share. It shifts the focus away from his grief. Option B gives advice that encourages avoiding the feelings. Grieving involves thinking about the person, and keeping busy to avoid it can delay healing. Option C minimizes the loss. "At least" statements tell the client that his grief should be smaller than it is.

The teaching point

Grief = ACKNOWLEDGE the loss and the feeling. Stay present. Avoid → "at least," "better place," "stay busy," "I know how you feel." Stating the obvious with empathy can be the best answer.