ANOTHER study guide for MED SURG TEST2

The nurse is caring for a 90 year old client who has never completed an advanced directive. The client has a child but has not seen the child in several years. A neighbor hs assisted this client with meals and housecleaning for years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged child wants the client to be treated aggressively. Which would be the nurse's initial step?

Assess the client's ability to state wishes

The nurse is caring for a client who is dying in a hospice setting. The family is unsure whether to go home for rest or spend the night with the client. Which body system would the nurse assess to provide the FIRST data on decline?

Cardiovascular system

A wound care nurse approaches a client to instruct in home care needs. In which clinical scenario would the nurse delay teaching due to learning readiness?

The client is anxious about physical therapy

Which of the following means of comprehending new information best describes a cognitive learner?

The learner processes information by listening to the facts

The nurse is caring for a client who just learned of a terminal diagnosis. After the health care provider leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?

The principle of autonomy

Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kubler-Ross' emotional reactions to dying?

"I understand that it would be wonderful to see your daughter's graduation"

The nurse is caring for a client who avoids looking the nurse straight in the eye. Which considerations should the nurse account for when providing care for the client?

-Avoiding eye contact may be a sign of respect -Direct eye contact may be viewed as an invasion of privacy -Determining the cause of the client's behavior may be accomplished by generalization

Which key information can the nurse provide to the client regarding the health related benefits of herbals and botanicals?

-Certain herbs can interact with prescription drugs -Not all herbs are safe

Which of the following is the nurse's primary concerns when providing end of life care for a client and the family?

-Maintaining client comfort -Supporting family members -Providing personal care

The nurse is providing end of life care to a client who is able to take oral foods and fluids. What actions should the nurse consider to ensure the client has good nutrition?

-Offer favorite or traditional food to stimulate the client's appetite -Administer an antiemetic en hour prior to meals to prevent nausea and vomiting

A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client?

-Provides pain relief -Integrates spirituality

The nurse is completing a cultural heritage assessment. Which items will be included in this portion of the health assessment?

-Religion - Participation in religious traditions -Hygiene practices -Management of symptoms

A nurse has been caring for a client and family for 6 months in a long term care facility. Which nursing action is appropriate during the terminating phase pf the nurse-client relationship?

-Teach the client and family about care needs at home -Relay well wishes from the staff -Arrange health related services to support home health care -Coordinate medication regimen for home care

The nurse is instructing a client in a crowded semiprivate room. The nurse approaches and moves equipment to allow for a comfortable conversation. At which distance should the nurse stand?

2-3 feet

A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing?

Acceptance

The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress?

the choice of palliative care over focused

The nurse cares for multiple ethnic populations. Which of the following examples best demonstrates a facility adhering to The Joint Commission requirements that healthcare workers facilitate communication with all clients?

the facility requests bilingual staff and community members to voluntarily provide contact info for interpreter services

The nurse is discharging a client with an indwelling Foley catheter. Which instructional method is best when teaching a psychomotor learner about the care necessary?

Provide the Foley catheter and equipment to hand and practice care

Which nursing action is most therapeutic when a client says "My daughter wants me to to a nursing home to get rid of me; I am a burden."

Pull up a chair and sit down to talk

Which cardiovascular findings indicate to the nurse that the condition of the client who is dying is worsening ?

Pulse 104 beats/minute in the morning. 62 beats/minute in the afternoon with mottled feet and ankles

What is the primary reason the nurse needs to ascertain client use of vitamins and minerals and the dosage of each?

The recommended daily allowance may vary with special populations

A nurse is providing care to a client who speaks and minimally understand, but whose primary language is different from, the dominant language. The client is accompanied by the spouse, who speaks and understands the dominant language weak The client requires surgery and will need to sign consents for treatment. Which is the best action for the nurse to take to ensure the client understands the plan of care?

Use an interpreter, preferably of the same sex, to explain the plan of care.

Which action, following the death of a loved one, might the nurse witness the family members of Chinese descent doing?

Washing the body

A client with the diagnosis of ovarian cancer confides practicing holistic medicine to the nurse. The client believes a cure exists through a macrobiotic diet, rather than what a surgery or medical treatment can achieve. Which statement by the nurse is most appropriate?

We can talk to your provider about adding this diet as complementary therapy

What is the best response when explaining biofeedback to a client?

it allows reduction of symptoms through voluntary control measures