A 29-year-old lone female parent of three children, who is ...

[ereecah]

A 29-year-old lone female parent of three children, who is currently pregnant, comes into the well-child clinic for a prenatal visit.
 
  To determine how the patient will be able to cope with the pregnancy, which of the following questions should the nurse ask her? a. Have you ever been married?
  b. Where do you work now?
  c. Has anyone taught you the principles of contraception?
  d. Whom do you have for support during this pregnancy?

Question 2

The nurse has determined the following outcome for a client with a skin impairment: Erythema will be reduced in three days. On what will the evaluation specifically focus?
 
  a. Selection of appropriate wound care
  b. Notation of the odour and colour of drainage
  c. Inspection of the colour and condition of the area
  d. Measurement of the diameter of the ulceration daily

[Brummell1998]

Answer to Question 1

D

Feedback
A Asking the patient whether she has ever been married does not assess her ability to cope with the pregnancy.
B Asking the patient where she works may help determine if any environmental factors may place her pregnancy at risk but does not assess her ability to cope with the pregnancy.
C This would not be the most opportune time to discuss contraception with the patient and may convey a message of disapproval, and asking the patient about contraception does not assess her ability to cope with the pregnancy.
D This could be a situational crisis for a lone-parent family. The nurse should assess environmental and familial factors, including support systems and coping mechanisms commonly used.

Answer to Question 2

C

Feedback
A Selection of appropriate wound care is an intervention, not an evaluation of a client's behaviour or response. The outcome criterion does not state anything about drainage.
B Noting the colour and amount of drainage may be a part of reassessment of the client but is not what the nurse is evaluating according to this outcome criterion.
C Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the colour of the skin, as stated in the outcome criterion.
D The outcome criterion states that the erythema, not the size of the ulceration, will be reduced. During the evaluation step of the nursing process, the client's behaviour or response should be compared to the outcome criterion and judged for the degree of agreement between the two.