ati g&d young adult and up

The nurse is caring for a terminally ill client who is unresponsive to verbal stimuli. The client's spouse asks if her husband can still hear her. Which is the best response by the nurse?

"Assume that your husband can still hear you."

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?

"I will contact the medical examiner regarding your request."

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

"It's been so stressful for me to think about having intimate relationships."

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement?

"Palliative care interventions hasten death."

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response?

"This must be very hard for you."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse should respond by making which statement?

"What do you and your husband believe is the right thing for your children?"

Following the death of her husband, a wife feels that he still with her. She also reports having dreams and vivid memories of him. Which question should the nurse ask to assess the sense of presence that the wife has described?

"how do you feel about these dreams and experiences"

Source

(Taylor 1627-1628)Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

In the care of dying patient, which tasks can be delegated to the unlicensed assistive personnel (UAP)? select all that apply

-assist the patient into a position of comfort -assist the patient with taking oral fluids -ensure that patient is clean and dry, and linens are changed as needed

What signs and symptoms would the nurse expect to observe in the patient who is nearing death? select all that apply

-lowered blood pressure -irregular respiratory pattern -mouth-breathing with dry mucous membranes

Which actions indicate that the health care team is fulfilling the Dying Person's Bill of Rights? select all that apply

-nurse assesses pain and administers pain -patient's choice of spiritual leader is contacted and rituals are allowed -nurse gives comfort measures and talks to patient who is in a coma -patient is allowed to make decisions, even though she seems indecisive

What is most likely to be included in postmortem care? select all that apply

-wash hands and don gloves -care for valuables and personal belongings -close patient's eyes and mouth if needed -place patient supine with arms at the sides

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Delirium 2. Depression 3. New-onset dementia 4. Worsening dementia

1

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply) 1. The loss of his work role 2. The risk of social isolation 3. A determination if the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose

1 4

A 71-year-old patient enters the emergency department after falling down the stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing the stairs. He is alert, orientated, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1 4 5

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

1, 2, 3 Previous experiences, religious affiliation, and cultural practices help individuals develop coping and can be a source of support at the end of life.

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

1, 2, 3, 4 Culture, spirituality, personal beliefs and values, and previous experiences with death influence how a person approaches death.

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

1, 2, 4 Palliative care is available to all patients regardless of age, diagnosis, and prognosis.

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

1, 2, 4, 5 A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers.

What findings are considered normal for a patient of Mr. Calder's age (87)? (Select all that apply) 1 Thin skin 2 Decreased saliva production 3 Decreased muscle strength 4 Whitening of the eye lens

1,2,3

Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the knowledge base of both the middle-age patient with a chronic illness and his family, the assessment should include which of the following? (Select all that apply.) 1 The medical course of the illness 2 The prognosis for the patient 3 Coping mechanisms of the patient and family 4 The need for community and social services

1,2,3,4

Intimate partner violence (IPV) is linked to which of the following factors? (Select all that apply.) 1 Alcohol abuse 2 Pregnancy 3 Unemployment 4 Drug use

1,2,3,4

A 45-year-old obese woman tells the nurse that she wants to lose weight. After conducting a thorough assessment, the nurse concludes that which of the following may be contributing factors to the woman's obesity? (Select all that apply.) 1 The woman works in an executive position that is very demanding. 2 The woman works out at the corporate gym at 5 AM two mornings per week 3 The woman says that she has little time to prepare meals at home and eats out at least four nights a week. 4 The woman says that she tries to eat "low cholesterol" foods to help lose weight.

1,3

Formation of positive health habits may prevent the development of chronic illness later in life. Which of the following are examples of positive health habits? (Select all that apply.) 1 Routine screening and diagnostic tests 2 Unprotected sexual activity 3 Regular exercise 4 Excess alcohol consumption

1,3

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

1,3,4,5 A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs.

A single young adult female interacts with a group of close friends from college and work. They celebrate birthdays and holidays together. In addition, they help one another through many stressors. She views these individuals as: 1 Family. 2 Siblings. 3 Substitute parents. 4 Alternative family structure.

1.

Middle-age adults frequently find themselves trying to balance responsibilities related to employment, family life, care of children, and care of aging parents. People finding themselves in this situation are frequently referred to as being a part of: 1 The sandwich generation. 2 The millennial generation. 3 Generation X. 4 Generation Y.

1.

Sexually transmitted infections (STIs) continue to be a major health problem in young adults. Men ages 20 to 24 years have the highest rate of which STI? 1 Chlamydia 2 Syphilis 3 Gonorrhea 4 Herpes zoster

1.

Which of the following might be a cause of stress for young adults? 1 Being single 2 Career 3 Sexuality 4 Activity

1.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services

2, 4 Palliative care and hospice care are different. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms.

A 50-year-old male patient is seen in the clinic. He tells the nurse that he has recently lost his job and his wife of 26 years has asked for a divorce. He has a flat affect. Family history reveals that his father committed suicide at the age of 53. The nurse should assess for the following: 1 Cardiovascular disease 2 Depression 3 Sexually transmitted infection 4 Iron deficiency anemia

2.

With the exception of pregnant or lactating women, the young adult has usually completed physical growth by the age of: 1 18. 2 20. 3 25. 4 30.

2.

The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action by the nurse? a. Suggest that the patient think it over and wait a few days before contacting the school. b. Direct the patient to ask his family about the possibility of starting a scholarship. c. Assess the patient's mental status to ensure that he is competent to make the decision. d. Assist the patient to find the necessary information about endowed scholarships.

ANS: D As the patient's advocate, the nurse should help provide the necessary information for the patient to set up a scholarship if that is his decision. The patient does not need to discuss the subject with his family first, and assessment of the patient's mental status is not needed. The patient may not have the time to wait a few days before contacting the university.

The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. The nurse knows which goal to be most appropriate for this patient? a. The patient will be referred to medical social services for evaluation and counseling. b. The patient will be encouraged to describe previous stressors and coping mechanisms. c. Nursing staff support patient's coping attempts and encourage verbalization of feelings. d. The patient will use effective coping strategies with no alcohol consumption.

ANS: D Goals are met by the patient rather than nursing or medical staff. The patient's use of effective coping strategies without drinking alcohol is an appropriate goal. Referring the patient for counseling and encouraging the patient to verbalize stressors are interventions rather than goals.

The nurse is caring for an emergency room patient who died because of a mishap with a loaded gun. The patient's body will be transported to the coroner's office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital? a. Endotracheal tube b. Foley catheter and IV line c. Dentures d. Necklace and watch

ANS: D Medical devices and tubes are not removed from the body if an autopsy is to be performed. The patient's necklace and watch may be removed and given to the patient's family members before the body is transported to the coroner's office for autopsy. Dentures should be left in the patient's mouth.

When helping a person through grief work, the nurse knows: A Coping mechanisms that were effective in the past are often disregarded in response to the pain of a loss B A person's perception of a loss has little to do with the grieving process. C The sequencing of stages of grief may occur in order, they may be skipped, or they may recur D Most clients want to be left alone

C. Grief is manifested in a variety of ways that are unique to an individual and based on personal experiences, cultural expectations, and spiritual beliefs. The sequencing of stages or behaviors of grief may occur in order, they may be skipped, or they may reoccur. The amount of time to resolve grief also varies among individuals.

When a client is confused, left alone with the side rails down, and the bed in a high position, the client falls and breaks a hip. What law has been broken? A Assault B Battery C Negligence D Civil tort

C. Knowing what to do to prevent injury is a part of the standards of care for nurses to follow. Safety guidelines dictate raising the side rails, staying with the client, lowering the bed, and observing the client until the environment is safe. As a nurse, these activities are known as basic safety measures that prevent injuries, and to not perform them is not acting in a safe manner. Negligence is conduct that falls below the standard of care that protects others against unreasonable risk of harm.

A nurse is caring for an older adult client. Which of the following physiologic changes associated with aging can affect medication dosage in this client? A. Increased glomerular filtration rate B. Decreased body fat C. Decreased gastric motility D. Decreased gastric pH

C. Decreased gastric motility

A nurse is caring for an older adult client who has pneumonia. Which of the following physiologic changes associated with aging places the client at a greater risk for pneumonia? A. Decreased anterior-posterior diameter B. Increased diameter of the small airways C. Decreased number of cilia D. Increased alveolar surface area

C. Decreased number of cilia

A nurse is collecting data from an older adult client who states he is homeless. Which of the following findings should the nurse document as comorbidities for this client? A. Inadequate shelter and clothing for the weather B. Malnutrition and poverty C. Dementia and tuberculosis D. Lack of preventive health care and immunizations

C. Dementia and tuberculosis

A nurse in the clinic is assessing an older adult client for the second time this week. The client reports a decreased energy level, insomnia, and anorexia. Diagnostic tests are within the expected reference ranges. For which of the following conditions should the nurse screen the client? A. Sarcopenia B. Dementia C. Depression D. Diabetes

C. Depression

A nurse is caring for a child. Which of the following are physical manifestations of impending death? (Select all that apply.) A. Heightened sense of hearing B. Tachycardia C. Difficulty swallowing D. Sensation of being cold E. Cheyenne-Stokes respirations

C. Difficulty swallowing E. Cheyenne-Stokes respirations

A nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. The client has a new prescription for alendronate sodium. Which of the following findings in the client's history should the nurse recognize is a contradiction to this medication? A. Glaucoma B. Paget's disease C. Esophageal stricture D. Long-term corticosteriod use

C. Esophageal stricture This indicates for delayed esophageal emptying.

A nurse in a long-term care facility is promoting reminiscence among older adult clients. Which of the following actions should the nurse take? A. Establish a weekly pet therapy visitation program B. Place a calendar and clock in each resident's room C. Institute a daily storytelling hour D. Encourage all clients to eat their meals in the dining room

C. Institute a daily storytelling hour

A nurse is participating on a committee that is developing age-appropriate care standards for older adult clients. Which of the following of Erikson's developmental tasks should the nurse recommend as the focus? A. Intimacy B. Identity C. Integrity D. Initiative

C. Integrity

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply.

Close the client's eyes. Elevate the head of the bed. Place wet saline gauze pads and a cool pack on the eyes.

A nurse is caring for a client who has Alzheimer's disease and refused to take her morning anti-hypertensive medication. The client is orientated to name and place and is able to perform ADLs with minimal supervision. Which of the following actions should the nurse take? A. Crush the pills and feed them to the client in applesauce B. Insist the client comply by informing her of the possible implications of missing a dose C. Notify the provider of the need for further evaluation of the client's level of competence D. Ask the client to express her reasons for refusing the medication and document the event

D. Ask the client to express her reasons for refusing the medication and document the event

A nurse is reinforcing teaching with an older adult client who has anemia. Which of the following foods should the nurse recommend to increase the client's iron intake? A. Greek yogurt B. Bran muffin C. Peanut butter sandwich D. Dried fruit

D. Dried fruit

A nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following information about pain management should the nurse include in the plan of care? A. Older adult clients have a diminished capacity to perceive pain B. Older adult clients should not take narcotics for pain control C. Older adult clients have increased pain as a normal part of aging D. Older adult clients are sensitive to the analgesic effect of opiates

D. Older adult clients are sensitive to the analgesic effect of opiates

A nurse is contributing to the plan of care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client? A. The client's skin will remain intact during hospitalization? A. The client's skin will remain intact during hospitalization B. The client will verbalize one new word each week C. The client will begin to help turn himself in bed, indicating improved mobility D. The client's airway will remain clear, as evidenced by clear breath sounds

D. The client's airway will remain clear, as evidenced by clear breath sounds

A nurse is reinforcing teaching with a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend that the clients complete annually? A. Cholesterol B. Colonscopy C. Diabetes mellitus D. Visual acuity

D. Visual acuity

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do not resuscitate (DNR) prescription. What is the nurse's priority action?

Notify the primary health care provider (PHCP) that the client is rescinding the DNR prescription.

The home health nurse is visiting an older patient who had an exacerbation of chronic obstructive pulmonary disease (COPD). Which finding best supports the nurse's analysis of dysfunctional grieving?

Patient ruminates over loss of health and vigor that started years ago

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action?

Provide a well-lighted room.

The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply.

Retain ritualism. Avoid significant changes in lifestyle. Maintain sensitivity toward the parents. Encourage the parents to be near the child. Encourage as normal an environment as possible.

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply).

Spend time focusing on improving job performance Welcome opportunities to be creative and productive Become involved with community issues and activities

A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient's spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best? a. "Don't worry. Your spouse will get over this phase soon." b. "Anger is an expected part of the grieving process." c. "Would your spouse be open to professional counseling?" d. "This diagnosis is difficult to handle; just be patient."

ANS: B Anger is one of the stages of grief as identified by Elizabeth Kubler-Ross. The nurse would first explain this to the spouse. Telling the spouse the patient will get over the phase soon or that the diagnosis is difficult to handle is false reassurance and dismissive of the concerns. It is too early to consider counseling although the patient may need it later. This is also a yes/no question which is not therapeutic.

Which statement by the patient indicates to the nurse that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness? a. "I am praying every day that this last round of chemotherapy will work." b. "I want to spend what time I have left at home with my grandchildren." c. "I need to meet with my financial planner to make sure my life insurance is all set." d. "I am concerned that my wife won't be able to live on her own after my death."

ANS: B Hospice care is provided to patients who are terminally ill and wish to have no further aggressive treatment in attempt to cure the disease. The patient's statement that she just wants to be home with her grandchildren indicates a readiness for hospice care.

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood?

The client expresses concerns about the next generation

4. A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying? a. Acceptance b. Anger c. Bargaining d. Denial

a. Acceptance

1. A nurse midwife is assisting a patient to deliver a full-term baby. The patient is firmly committed to natural childbirth and has attended each natural childbirth class in preparation for labor and delivery. A cesarean delivery becomes necessary when her fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational

a. Actual b. Perceived c. Psychological

9. A patient diagnosed with breast cancer who is in the end stages of her illness has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse caring for the patient that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. The nurse and husband both agree that this seems to be all that therapy is now doing for her. The nurse would suggest that the husband speak to his wife's physician about which type of order? a. Comfort-measures-only b. Do-not-hospitalize c. Do-not-resuscitate d. Slow-code-only

a. Comfort-measures-only

5. A nurse is visiting a male patient with pancreatic cancer who is dying at home. During the visit, he breaks down and cries and tells the nurse that it is unfair that he should have to die now when he's finally made peace with his family and wants to live. Which response by the nurse would be most appropriate? a. "You can't be feeling this way. You know you are going to die." b. "It does seem unfair. Tell me more about how you are feeling." c. "You'll be all right; who knows how much time any of us has" d. "Tell me about your pain. Did it keep you awake last night?"

b. "It does seem unfair. Tell me more about how you are feeling."

6. A nurse is caring for a terminally ill patient during the 11 PM to 7 AM shift. The patient says, "I just can't sleep. I keep thinking about what my family will do when I am gone." What response by the nurse would be most appropriate? a. "Oh, don't worry about that now. You need to sleep." b. "What seems to be concerning you the most?" c. "I have talked to your wife and she told me she will be fine." d. "I have to go and give medicines, you should discuss this with your wife."

b. "What seems to be concerning you the most?"

12. A nurse is caring for terminally ill patients in a hospital setting. Which example describes appropriate end-of-life care? a. To eliminate confusion, taking care not to speak too much when caring for a comatose patient b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient c. Referring to a counselor the daughter of a dying patient who is complaining about the care associated with artificially feeding her father d. Telling a dying patient to sit back and relax and performing patient hygiene for the patient because it is easier than having the patient help

b. Sitting on the side of the bed of a dying patient, holding the patient's hand, and crying with the patient

11. All of the following diagnoses may apply to a young couple who gave birth to a premature infant with serious respiratory problems who has been in the neonatal intensive care unit for the last 3 months. The couple has a 22-month-old son at home. Which diagnosis would be most appropriate based on the following assessment data: report of chronic fatigue and decreased energy, guilt about neglecting son at home, shortness of temper with one another, and apprehension about continued ability to go on this way? a. Grieving b. Ineffective Coping c. Caregiver Role Strain d. Powerlessness

c. Caregiver Role Strain

3. A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing? a. Abbreviated b. Anticipatory c. Dysfunctional d. Inhibited

c. Dysfunctional

7. A patient tells a nurse that he has no one he trusts to make health care decisions for him should he become incapacitated. What should the nurse suggest he prepare? a. Combination advance medical directive b. Durable power of attorney for health care c. Living will d. Proxy for health care

c. Living will

On seeing the body of his little brother who just died from cancer, a 10-year-old sibling screams, "I won't go to the funeral!" I won't go!" The mother is sobbing and the father begins to yell. What should the nurse do first?

calmly close the door and stay with the family while they express themselves

The patient is sobbing. When the nurse tries to find out what is wrong, the patient angrily says, "I'm dying! I have pain! My children are losing their mother! We are in debt up to our eyeballs! And God seems to be on a coffee break!" What does the nurse do first to identify and prioritize the patient's problems?

collect additional data about each concern and consult with the RN

The terminally ill patient has been experiencing severe pain and has requested that the physician assist her to end her suffering. What should the nurse do if the physician prescribes a morphine dosage that could cause respiratory depression and respiratory arrest?

consult the nursing supervisor for advice

Which nursing action demonstrates that the nurse is performing his/her responsibilities according to the National Organ Transplantation Act (Public Law 98-507, 10-14, 1984) and the Uniform Anatomic Gift Act?

contacts a qualified health care professional to ask family about organ donation

14. The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? a Inform the family that there is no need for them to wash the body since the mortician typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. c. Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

The nurse is teaching the entire family, which includes a preschooler and a school-aged child, about how to care and interact with older member of the family who is dying and being cared for at home. Which activities would be best to suggest to the preschooler and school-aged child, respectively?

draw a picture for grandma and organize her photo album

As the nurse is performing medication teaching, the older woman begins to cry. "My grandson got into my pills and overdosed. He didn't die, but my daughter won't even speak to me." What is the most therapeutic response?

every time you look at your medicine, you think about your family

The hospice nurse is visiting a family of a deceased patient. During the visit, the son displays symptoms of a grief attack. Which intervention would the nurse use?

help the son recognized that the attack is a type of grief response

Which nursing action supports the structure and process of care and represents one of the eight domains established by the National Consensus Project for Quality Palliative Care?

helps the patient to identify previously used coping strategies and develop new ones

The nurse is caring for hospice patient who has frequently experiencing episodes of pain and dyspnea. The family is devoted and frequently visits, but today the patient is difficult to arouse, and they cause the nurse of over medicating patient. What should the nurse do first?

listen to their concerns and clarify their goals for the patient

On assessing the dying patient, the nurse notes that the pulse rate is 30/min, the respiratory rate is 8/min, and the systolic blood pressure is palpated at 60. The patient has a Do Not Resuscitate (DNR) order. What should the nurse do first?

make the patient comfortable

Which statement by the family member of dying patient best indicates a healthy retention of hope?

my sister is coming from California next week, I know he wants to see her

Which outcome statement best indicates that one of the primary goals of palliative care has been met?

patient reports relief from pain and nausea

A student who normally gets "As" receives a "Cs" on her project and experiences a loss of confidence. Which behavior best indicates that the student is achieving growth because of this situation loss?

requests a review of the project's strengths and weaknesses against the criteria

A nurse is talking to a 63-year-old woman who underweight grief therapy for unresolved grief related to the death of her husband. Which behavior best indicates that the therapy is helping?

she talks about things they used to enjoyed

Which action is the best indicator that an older widow is moving through grief towards closure?

sorts through husband's belongings and saves some items for grandchildren and donates the rest

The nurse has good relationship with an older man who was recently placed on hospice care. He speaks fondly about his adult children but admits to being very rough on them while they were growing up. What should the nurse do first to facilitate anticipatory grieving for the man and his family?

talk to the man about his perception of his current relationship with his children

The patient tells the nurse that he has a durable power of attorney for health care and medical treatment. What is the most important information to obtain from the patient?

the name and phone number of the person who will make health care decisions

For which patient should the nurse design and implement interventions to facilitate anticipatory grief?

young athlete is informed that he needs a below-the-knee amputation due to osteosarcoma

A hospice program emphasizes: A. Prolongation of life B. Hospital-based care C. Palliative treatment and control of symptoms D. Curative treatment and alleviation of symptoms

C

A recently graduated nurse is caring for a client who was just given the diagnosis of pancreatic cancer. The client asks the nurse to help her understand this death sentence and tell her why God did this to her, as she has lived a good life all along. The nurse, not being comfortable as a spiritual counselor, should do which of the following? a) Tell the client that she will talk about this later b) Tell the client she does not want to talk about this because she is not comfortable doing so c) Suggest to the client that she can call her spiritual advisor to help give her counsel d) Change the subject to avoid focusing on the new diagnosis

C

All of the following are crucial needs of the dying patient except: A. Control of pain B. Love and belonging C. Freedom from decision making D. Preservation of dignity and self-worth

C

An elderly person in end-stage renal disease is admitted to a nursing home for palliative care. Nursing interventions will be: A. Ambulation as desired. B. Assessment for urinary output. C. Pain relief. D. CPR if needed

C

Can no longer feel, hear, or know a person or object. A. Maturational losses B. Situational lossess C. Actual loss D. Perceived loss

C

Captures grief and mourning, emotional responses, and outward behaviors for a person experiencing loss. A. Grief B. Mourning C. Bereavement D. Normal Grief E. Complicated Grief

C

Describe Worden's tasks of mourning: A. Denial, Anger, Bargaining, Depression, Acceptance. B. Numbing, Yearning/Searching, Disorganization/Dispair, Reorganization. C. Accept reality, Experience pain, Adjust, Move on with life. D. Recognize loss, React/express pain, Reminisce, Relinquish attachments, Readjust.

C

Difficult to process because of the lack of finality and unknown outcomes. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

C

The nurse is explaining about palliative care to the client. Which statement by the client indicates that teaching was effective? a) "I will need to stay in the hospital until my symptoms are under control." b) "There is nothing that can be done for my chronic nausea and vomiting." c) "The healthcare team will work together to get my symptoms under control." d) "I need to get my affairs in order since I can expect to live only 6 more months."

C

When opioids are prescribed for pain at the end of life, the nurse should understand that: A. Death is likely to be soon. B. Opioids most likely will be a PRN order. C. Side effects still must be treated. D. Other medications are no longer useful for the client

C

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? a) "Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis." b) "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops." c) "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." d) "The client will have to go to an inpatient hospice unit in order to receive palliative care."

C

A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. What should the nurse explain? a. Those symptoms are normal when a woman undergoes the climacteric. b. An assessment is not really needed because these problems are normal for older women. c. The patient's age and symptoms point toward normal menopause. d. The patient should stop regular exercise because that is probably causing her symptoms.

C.

During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. What is the nurse's best action in response to this finding? a. Explain to the patient that breast tenderness is normal at her age. b. Tell the patient that redness is not a cause for concern and is quite common. c. Assess the patient as thoroughly as possible. d. Inform her that redness is the precursor to normal unilateral breast enlargement.

C.

The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which statement by the nurse accurately describes these changes? a. "Pregnancy enhances your ability to cope with stress." b. "Being nauseated and feeling tired will not affect your physical body image." c. "You and your partner may experience feelings of uncertainty about assuming the roles of parents." d. "Returning home after delivery will rejuvenate you and foster independence."

C.

The nurse knows that the young adult patient understands the health risks that affect his/her age group when the patient states a. "It's probably safe for me to start smoking. At my age, there's not enough time for cancer to develop." b. "I am sure that I am going to get emphysema. Both my mother and my aunt had it. It's genetic." c. "Controlling the amount of stress in my life may decrease the risk of illness." d. "I don't do drugs. I do drink coffee, but caffeine is not a drug. It is perfectly safe and has no side effects."

C.

Trying questionable and experimental forms of therapy is a behavior that is characterized of which stage of dying? A Anger B Depression C Bargaining D Acceptance

C.

When describing relevant family psychosocial factors in middle adulthood that cause stress, the nurse would not include a. Singlehood and feeling isolated. b. Choices stemming from marital changes. c. Financial security and certainty. d. Planning for the future when children leave home.

C.

Which statement about loss is accurate? A Loss is only experienced when there is an actual absence of something valued B The more the individual has invested in what is lost, the less the feeling of loss C Loss may be maturational, situational, or both. D The degree of stress experienced is unrelated to the type of loss

C.

When providing prenatal care, what information does the nurse expect to provide? (Select all that apply.) a. Protecting against urinary infection b. No longer needing condoms c. Exercise patterns d. Proper diet e. Physical assessments only during the last trimester

A, C, D

A 25-year-old patient is brought to the hospital by police after crashing his car in a high-speed chase when trying to avoid arrest for spousal abuse. What should the nurse do? a. Question the patient about drug use. b. Offer the patient a cup of coffee to calm his nerves. c. Be aware that substance abuse is usually obvious. d. Deal with the issue at hand, and put off asking about previous illnesses.

A.

A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. What should the nurse tell the patient? a. Lamaze classes can prepare pregnant women and their partners for what is coming. b. The frequency of sexual intercourse is key to helping the husband feel valued. c. After the birth, the stress of pregnancy will disappear and will be replaced by relief. d. After the baby is born, the wife should accept the extra responsibilities of motherhood.

A.

The nurse is caring for a hospitalized young adult male who is uninsured even though he works as a dishwasher at a local restaurant. He states that he would like to get a better job, but he has no education. How can the nurse best assist this patient psychosocially? a. By providing information and referrals b. By telling the patient that he needs to go back to school c. By focusing on the patient's medical diagnoses d. By expecting the patient to be flexible in his decision making

A.

A nurse is reinforcing discharge teaching about calcium supplements with an older adult female client who has osteoporosis and recent repair of a fracture in her right hip. Which of the following instructions should the nurse include? A. "You should take your calcium supplement with a large glass of water." B. "You should increase your intake of grain cereals while taking calcium supplements." C. "You should take at least 2600 milligrams of calcium supplements daily." D. "You will not need to take vitamin D with your calcium supplement because you are postmenopausal."

A. "You should take your calcium supplement with a large glass of water."

Which of the following might be a cause of stress for the older adult? A. Financial security B. Planned retirement C. Housing D. Adjusting to decreasing health and physical strength

A. Financial security C. Housing D. Adjusting to decreasing health and physical strength

A nurse at an ophthalmology clinic is collecting data from a client referred by the provider for a potential cataract. Which of the following client reports should the nurse recognize is consistent with cataracts? A. Halos when looking at lights B. Loss of peripheral vision C. Bright flashes of light and floaters D. Eyestrain and headache with close work

A. Halos when looking at lights

A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has approved the family to bring food from home. Which of the following foods should the nurse recommend that the client not eat? A. Lentil soup B. Cheese sandwich C. Yogurt D. Dried fruits

A. Lentil soup

A nurse at an assisted living center is conducting an orientation session for a group of newly hired assistive personnel (AP). Which of the following instructions should the nurse include regarding clients who are hearing impaired? A. Maintain eye contact with the clients B. Stand to one side of the clients and speak into their good ears C. Speak loudly with exaggerated enunciation D. Ask only question with yes or no answers

A. Maintain eye contact with the clients

A nurse is reinforcing dietary teaching with an older adult client who is on bedrest following development of deep vein thrombosis (DVT) about to increase peristalsis. Which of the following high-fiber food choices should the nurse recommend? A. Navy bean soup B. Canned fruit juice C. White rice pudding D. Soy milk

A. Navy bean soup

A nurse is assisting with the care of an older adult client who has dementia. The client becomes agitated and confused at night and wanders into the hallway. Which of the following actions should the nurse take? A. Place the client's mattress on the floor B. Restrain the client during the nighttime hours C. Provide continuous orientation to the client D. Turn out the lights in the client's room at night

A. Place the client's mattress on the floor

A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration? A. Review the medical record for a client history of glaucoma B. Plan to administer the medication 30 min prior to a meal C. Explain to the client he will need to restrict his fluid intake once he takes the medication D. Remind the client that his appetite might increase when starting the medication

A. Review the medical record for a client history of glaucoma

A nurse at a long-term care facility is assisting with planning care for a group of older adult clients. When planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following? A. Short-term memory B. Creative ability C. Decision-making skills D. Cognitive capacity

A. Short-term memory

A nurse is teaching a parent of a preschool child about factors that affect the child's perception of death. Which of the following should be included in the teaching? A. Preschool children have no concept of death. B. Preschool children perceive death as temporary. C. Preschool children often regress to an earlier stage of behavior. D. Preschool children experience fear related to the disease process.

B. Preschool children perceive death as temporary.

A nurse often cares children who are dying. Which of the following is an appropriate action for a nurse to take to maintain their effectiveness? (Select all that apply.) A. Remain in contact with he family after their loss. B. Develop a professional support system. C. Take time off work. D. Suggest that a hospital representative attend the funeral. E. Demonstrate feelings of sympathy toward the family.

A. Remain in contact with he family after their loss. B. Develop a professional support system. C. Take time off work.

A nurse is teaching a parent about complicated grief. Which of the following statements by the nurse is appropriate? A. "It is considered complicated grief if you are still grieving 6 months after your loss." B. "Personal activities are affected when experiencing complicated grief." C. "Parents will experience complicated grief together." D. "Complicated grief self-resolves in 12 months."

B. "Personal activities are affected when experiencing complicated grief."

An elderly client whose middle-age daughter recently died of breast cancer now complains of mild abdominal pain, five-pound weight loss, insomnia, and fatigue. When no physiological cause can be found, the nurse suspects these are symptoms of: A. Hypochondria. B. Normal grieving. C. Spiritual distress. D. Denial

B

Describe Bowlby's attachment theory of mourning: A. Denial, Anger, Bargaining, Depression, Acceptance. B. Numbing, Yearning/Searching, Disorganization/Dispair, Reorganization. C. Accept reality, Experience pain, Adjust, Move on with life. D. Recognize loss, React/express pain, Reminisce, Relinquish attachments, Readjust.

B

Outward soical expression of grief and the behavior associated with loss that can be culturally influenced. A. Grief B. Mourning C. Bereavement D. Normal Grief E. Complicated Grief

B

Sudden, unpredicable external event. A. Maturational losses B. Situational lossess C. Actual loss D. Perceived loss

B

Suppressing or postponing normal grief responses. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

B

Trying questionable and experimental forms of therapy is a behavior that is characteristic of chiech stage of dying? A. Anger B. Bargaining C. Depression D. Acceptance

B

When an elderly client expresses a wish to forgo additional treatment for cancer and to die, a priority action of the nurse would be: A. Call the family. B. Explore the client's understanding of the consequences of such a decision. C. Suggest the client reconsider the finality of the decision. D. Call the physician.

B

When discussing culture, the nurse educator correctly identifies which terminology to describe a health care practitioner who is respectful of the health care traditions of other cultures? a) Culturally impositive b) Culturally sensitive c) Culturally competent d) Culturally appropriate

B

Which is not important when assessing for Grief? A. Coping style B. Electrolyte balance C. Relationships D. Personal goals E. Beliefs F. Support systems G. Sources of hope

B

The nurse puts a restraint jacket on a client without the client's permission and without the physicians order. The nurse may be guilty of: A Assault B Battery C Invasion of privacy D Neglect

B.

What should the nurse recognize when comparing the physical changes in young and middle adulthood? a. Fertility issues do not occur in young adulthood. b. Young adults are quite active but are at risk for illness in later years. c. Young adults tend to suffer more from severe illness. d. Exercise is less important in young adulthood than in middle adulthood.

B.

When choosing an appropriate topic for a young adult health fair, the nurse ranks which topic as least relevant? a. Unplanned pregnancies b. Menopause and climacteric factors c. Smoking cessation d. Alcohol and drug use

B.

1. The client tells the nurse, "Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?" Which statement by the nurse is most appropriate? 1. "You must fill out this form because Medicare laws require it." 2. "An AD lets you participate in decisions about your health care." 3. "This paper will ensure no one can override your decisions." 4. "It is part of the hospital admission packet and I have to give it to you." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

1. 1. Advance directives (AD) are not legally required. It is a standard of the Joint Commission, and any facility which accepts federal funds must ask and offer the AD. 2. ADs allow the client to make personal health-care decisions about end-of-life issues, including cardiopulmonary resuscitation (CPR), ventilators, feeding tubes, and other issues concerning the client's death. 3. This is not a legal document guaranteed to stand up in a court of law; therefore, the client should make sure all family members know the client's wishes. 4. It is part of the hospital admission requirements, but it is not the reason why the client should complete an AD. TEST-TAKING HINT: The test taker could eliminate option "1" because the nurse cannot make the client do anything. The client has a right to say no. Option "3" is an absolute, and unless the test taker knows for sure this is correct information, the test taker should not select this option. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 2

1. The 38-year-old client was brought to the emergency department with CPR in progress and expired 15 minutes after arrival. Which intervention should the nurse implement for postmortem care? 1. Do not allow significant others to see the body. 2. Do not remove any tubes from the body. 3. Prepare the body for the funeral home. 4. Send the client's clothing to the hospital laundry. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

1. 1. There is no reason the family members should not be able to see the client; this is important to allow the significant others closure. 2. This death should be reported to the medical examiner because the death occurred less than 24 hours after hospital admission and an autopsy may be required. Therefore, the nurse must leave all tubes in place; the medical examiner will remove the tubes. 3. This is a medical examiner case, and the nurse should not prepare the body by removing tubes or washing the body prior to taking the client to a funeral home. 4. The client's clothing should be given to the family or to the police if foul play is suspected. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 2

1. According to the World Health Organization, palliative care is an approach that improves quality of life for patients and their families who face problems associated with life-threatening illnesses. From the list below, identify the specific goals of palliative care (select all that apply). a. Regard dying as a normal process. b. Minimize the financial burden on the family. c. Provide relief from symptoms, including pain. d. Affirm life and neither hasten nor postpone death. e. Prolong the patient's life with aggressive new therapies. f. Support holistic patient care and enhance quality of life. g. Offer support to patients to live as actively as possible until death. h. Assist the patient and family to identify and access pastoral care services. i. Offer support to the family during the patient's illness and their own bereavement. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

1. a, c, d, f, g, i. Table 10-1 lists the goals of palliative care. Overall, goals of palliative care are to prevent and relieve suffering and to improve the quality of life for the patient. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

10. The male client requested a DNR per the AD, and the HCP wrote the order. The client's death is imminent and the client's wife tells the nurse, "Help him please. Do something. I am not ready to let him go." Which action should the nurse take? 1. Ask the wife if she would like to revoke her husband's AD. 2. Leave the wife at the bedside and notify the hospital chaplain. 3. Sit with the wife at the bedside and encourage her to say good-bye. 4. Request the client to tell the wife he is ready to die, and don't do anything. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

10. 1. Only the client can revoke the AD. 2. The wife should not be left alone, and the hospital chaplain may not be available for the client and his wife. 3. At the time of death, loved ones become scared and find it difficult to say good-bye. The nurse should support the client's decision and acknowledge the wife's psychological state. Research states hearing is the last sense to go, and talking to the dying client is therapeutic for the client and the family. 4. The client is dying and should not be asked to exert himself for his wishes to be carried out. TEST-TAKING HINT: Logic would suggest option "4" is not a viable answer. Leaving a grieving spouse would not be appropriate in any situation; therefore, the test taker should eliminate option "2." Option "1" denies the client's autonomy and is not an ethical or a legal choice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 3

12. Which client would the nurse exclude from being a potential organ/tissue donor? 1. The 60-year-old female client with an inoperable primary brain tumor. 2. The 45-year-old female client with a subarachnoid hemorrhage. 3. The 22-year-old male client who has been in a motor-vehicle accident. 4. The 36-year-male client recently released from prison. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

12. 1. Primary brain tumors rarely metastasize outside the skull, and this client can be a donor; cancers other than primary brain tumors prevent organ/tissue donation. 2. This is an excellent potential donor because all other organs are probably healthy. 3. This is an excellent candidate because this is a young person with a traumatic death, not a chronic illness. 4. A male client who has been in prison is at risk for being HIV positive, which excludes him from being an organ/tissue donor. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 4

10. The male client asks the nurse, "Should I designate my wife as durable power of attorney for health care?" Which statement would be the nurse's best response? 1. "Yes, she should be because she is your next of kin." 2. "Most people don't allow their spouse to do this." 3. "Will your wife be able to support your wishes?" 4. "Your children are probably the best ones for the job." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

10. 1. The client can designate anyone he wishes to be the durable power of attorney. 2. This is not true; many spouses are designated as the durable power of attorney for health care. 3. No matter who the client selects as the power of attorney, the most important aspect is to make sure the person, whether it be the wife, child, or friend, will honor the client's wishes no matter what happens. 4. The children must be at least 18 years old and willing to honor the client's wishes. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 3

10. A patient is receiving care to manage symptoms of a terminal illness when the disease no longer responds to treatment. What is this type of care known as? a. Terminal care c. Supportive care b. Palliative care d. Maintenance care Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

10. b. Palliative care is aimed at symptom management rather than curative treatment for diseases that no longer respond to treatment and is focused on caring interventions rather than curative treatments. "Palliative care" and "hospice" are frequently used interchangeably. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

11. Which situation would cause the nurse to question the validity of an AD when caring for the elderly client? 1. The client's child insists the client make his or her own decisions. 2. The nurse observes the wife making the husband sign the AD. 3. A nurse encouraged the client to think about end-of-life decisions. 4. A friend witnesses the client's signature on the AD form. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

11. 1. This is appropriate for completing an AD and would not make the nurse question the validity of the AD. 2. This is coercion and is illegal when signing an AD. The AD must be signed by the client's own free will; an AD signed under duress may not be valid. 3. The nurse encouraging the client to think about ADs is an excellent intervention and would not make the AD invalid. 4. A friend can sign the AD as a witness; this would not cause the nurse to question its validity. TEST-TAKING HINT: This is an "except" question. The test taker could ask, "Which situation is valid for an AD?" Remember, three answers are valid information for the AD and only one is not. The test taker should read all answer options and not jump to conclusions. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 2

11. The client has been declared brain dead and is an organ donor. The nurse is preparing the wife of the client to enter the room to say good-bye. Which information is most important for the nurse to discuss with the wife? 1. Inform the wife the client will still be on the ventilator. 2. Instruct the wife to only stay a few minutes at the bedside. 3. Tell the wife it is all right to talk to the client. 4. Allow another family member to go in with the wife. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

11. 1. This is the most important action because, when the wife walks in the room, the client's chest will be rising and falling, the monitor will show a heartbeat, and the client will be warm. Many family members do not realize this and think the client is still alive. The organs must be perfused until retrieved for organ donation. 2. The wife should be encouraged to stay a short time and leave the facility before the client is taken to the operating room, but it is not the most important intervention. 3. It is all right for the wife to talk to the client, but because the client is brain dead and cannot hear her, it is not the most important intervention. 4. It is all right for another family member to go into the room, but it is not the most important intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 1

11. Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse? a. Administer oxygen. b. Administer bronchodilators. c. Administer antianxiety agents. d. Use any methods that make the patient more comfortable. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

11. d. There currently are no clinical practice guidelines to relieve the shortness of breath and air hunger that often occur at the end of life. The principle of beneficence would encourage any of the options to be tried, based on knowing that whatever gives the patient the most relief should be used. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room 2. Adequate staffing is available for all residents 3. Social activities are available for all residents 4. The center provides three meals daily with a set menu and serving schedule 5. Staff encourage family involvement in care planning and assisting with physical care

2 3 5

12. The nurse is aware the Patient Self-Determination Act of 1991 requires the health-care facility to implement which action? 1. Make available an AD on admission to the facility. 2. Assist the client with legally completing a will. 3. Provide ethically and morally competent care to the client. 4. Discuss the importance of understanding consent forms. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

12. 1. The Patient Self-Determination Act of 1991 requires health-care facilities which receive Medicare or Medicaid funding to make ADs available to clients on admission into the facility. 2. This act is not concerned with completing a legal will. 3. Client care is not based on this act. 4. Consent forms are legal documents, which are not discussed in this act. TEST-TAKING HINT: The test taker should examine the word "self-determination" in the stem of the question, which matches the advance directive in option "1." The words "legally," "ethically," and "morally" in options "2" and "3" apply to the nurse in the healthcare setting, not the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 1

12. End-of-life palliative nursing care involves a. constant assessment for changes in physiologic functioning. b. administering large doses of analgesics to keep the patient sedated. c. providing as little physical care as possible to prevent disturbing the patient. d. encouraging the patient and family members to verbalize their feelings of sadness, loss, and forgiveness. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

12. d. In assisting patients with dying, end-of-life care promotes the grieving process, which involves saying goodbye. Physical care is very important for physical comfort but assessment should be limited to essential data related to the patient's symptoms. Analgesics should be administered for pain but patients who are sedated cannot participate in the grieving process. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 329). Elsevier Health Sciences. Kindle Edition.

13. The spouse of a client dying from lung cancer states, "I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?" Which is the hospice care nurse's best response? 1. "The body produces about two (2) teaspoons of fluid every minute on its own." 2. "Are you sure someone is not putting ice chips in her mouth?" 3. "There is no reason for this, but it does happen from time to time." 4. "I can administer a patch to her skin to dry up the secretions if you wish." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

13. 1. The respiratory tract cells produce liquid as a defense mechanism against bacteria and other invaders. About nine (9) mL a minute are produced. The "death rattle" can be disturbing to family members, and the nurse should intervene but not with suctioning, which will increase secretions and the need to suction more. 2. This is a natural physical phenomenon and should be addressed. 3. There is an explanation. 4. The scopolamine patch applied to the skin helps to limit the secretions, but this does not answer the question. TEST-TAKING HINT: The test taker could eliminate option "3" because it states there is no reason, option "4" because it does not answer the question, and option "2" because it is attempting to fix blame. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 1

13. The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en route to the hospital. Which statement would be an appropriate goal of treatment for the client? 1. The urinary output is 20 mL/hr via a Foley catheter. 2. The systolic blood pressure is greater than 90 mm Hg. 3. The pulse oximeter reading remains between 88% and 90%. 4. The telemetry shows the client in sinus tachycardia. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

13. 1. The urinary output should be at least 30 mL/hr. 2. The systolic blood pressure must be maintained at this rate to keep the client's organs perfused until removal. 3. The pulse oximeter should be greater than 93%. 4. The client's heart must be beating, but it can be normal sinus rhythm or even sinus bradycardia. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 2

13. The dying patient and family have many interrelated psychosocial and physical care needs. Which ones can the nurse begin to manage with the patient and family (select all that apply)? a. Anxiety d. Care being provided b. Fear of pain e. Anger toward the nurse c. The dying process f. Feeling powerless and hopeless Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 35). Elsevier Health Sciences. Kindle Edition.

13. a, b, c, d, e, f. Teaching, along with support and encouragement, can decrease some of the anxiety. Teaching about pain relief, the dying process, and the care provided will help the patient and family know what to expect. Allowing the patient to make decisions will help to decrease feelings of powerlessness and hopelessness. The nurse who is the target of anger needs to not react to this anger on a personal level. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 329). Elsevier Health Sciences. Kindle Edition.

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2 4

14. The nurse is discussing placing the client diagnosed with chronic obstructive pulmonary disease (COPD) in hospice care. Which prognosis must be determined to place the client in hospice care? 1. The client is doing well but could benefit from the added care by hospice. 2. The client has a life expectancy of six (6) months or less. 3. The client will live for about one (1) to two (2) more years. 4. The client has about eight (8) weeks to live and needs pain control. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

14. 1. Hospice care does not assume care of a client with a prognosis of more than six (6) months and who is doing well. 2. The HCP must think that, without lifeprolonging treatment, the client has a life expectancy of six (6) months or less. The client may continue receiving hospice care if the client lives longer. 3. The client may live this long, but the HCP must think life expectancy is much shorter. 4. Hospice will attempt to manage symptoms of pain, nausea, and any other discomfort the client is experiencing, but the life expectancy is six (6) months. TEST-TAKING HINT: This is a knowledgebased question requiring an understanding of hospice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 2

14. The nurse is teaching a class on ethical principles in nursing. Which statement supports the definition of beneficence? 1. The duty to prevent or avoid doing harm. 2. The duty to actively do good for clients. 3. The duty to be faithful to commitments. 4. The duty to tell the truth to the clients. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

14. 1. This is the ethical principle of nonmalfeasance. 2. This is the ethical principle of beneficence. 3. This is the ethical principle of fidelity. 4. This is the ethical principle of veracity. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 2

14. A deathly ill patient from a culture different than the nurse's is admitted. Which question is appropriate to help the nurse provide culturally competent care? a. "If you die, will you want an autopsy?" b. "Are you interested in learning about palliative or hospice care?" c. "Do you have any preferences for what happens if you are dying?" d. "Tell me about your expectations of care during this hospitalization." Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 35). Elsevier Health Sciences. Kindle Edition.

14. d. Using the open-ended statement to seek information related to the patient's and family's perspective and expectations will best guide the plan of care for this patient. This will open the discussion about palliative or hospice care and preferences for end-of-life care. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 329). Elsevier Health Sciences. Kindle Edition.

15. Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse? 1. The UAP is holding the phone to the ear of a client who is a quadriplegic. 2. The UAP refuses to discuss the client's condition with the visitor in the room. 3. The UAP put a vest restraint on an elderly client found wandering in the hall. 4. The UAP is assisting the client with arthritis to open up personal mail. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

15. 1. The client has a right to private phone conversations but, because the client is a quadriplegic, holding the phone to the ear does not require immediate intervention. 2. This is the appropriate action for the UAP and should be praised. 3. Restraints are not allowed unless there is a health-care provider's order with documentation by the nurse of the client being a danger to himself or others. The UAP's putting the client in restraints warrants immediate intervention because it is battery. 4. The client has a right to send and receive mail, and the UAP is helping the client open the mail; therefore, this does not require immediate intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 3

15. The client diagnosed with end-stage congestive heart failure and type 2 diabetes is receiving hospice care. Which action by the nurse demonstrates an understanding of the client's condition? 1. The nurse monitors the blood glucose four (4) times a day. 2. The nurse keeps the client on a strict fluid restriction. 3. The nurse limits the visitors the client can receive. 4. The nurse brings the client a small piece of cake. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

15. 1. This would be basic care, but it does not indicate the nurse is aware of the client's terminal prognosis. 2. This does not indicate an understanding of the client's terminal status. 3. The nurse should encourage visitors. There is not much time left for making memories, which will assist those left behind in dealing with the loss and allow the client time to say good-bye. 4. The client may have diabetes, but the client is also terminal, and allowing some food for pleasure is understanding of the client's life expectancy. TEST-TAKING HINT: This question requires the test taker to look not only at the disease processes but also at the descriptive words "end-stage" and "hospice" and ask, "What do these descriptors mean to the disease process?" Not limiting the client in small ways indicates the nurse is aware the client has a limited time to live. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 4

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry

2, 3, 5 Allowing patients to make choices about their care and end-of-life experience provides opportunities for them to maintain their autonomy

16. The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss? 1. The nurse must believe the client's report of pain. 2. Clients in chronic pain may not show objective signs. 3. Alternate pain-control therapies are used for chronic pain. 4. Referral to a pain clinic may be necessary. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

16. 1. The most important information for a nurse caring for a client with acute or chronic pain is to believe the client. Pain is subjective, and the nurse should not be judgmental. 2. This is a true statement because the client's sympathetic nervous system cannot remain in a continual state of readiness. This results in no objective data to support the pain and a normal pulse and blood pressure. However, it is not the most important information a new graduate should know. 3. Transcutaneous electrical nerve stimulation (TENS), distraction, imagery, acupuncture, and acupressure are all alternate pain therapies which may be used for chronic pain, but it is not the most important information the new graduate should know. 4. Pain clinics treat clients with chronic pain, but it is not the most important information a new graduate should know. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition.

16. The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention? 1. The client will ask all of his or her spiritual questions and get answers. 2. The nurse is able to explain to the client how death will affect the spirit. 3. Spirituality provides a sense of meaning and purpose for many clients. 4. The nurse is the expert when assisting the client with spiritual matters. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

16. 1. The nurse is not able to provide all spiritual answers to the client. 2. The nurse can explain physical aspects of death, but no one is able to tell the client with absolute knowledge what will happen to the soul or spirit at death. The beliefs of the client may differ greatly from those of the nurse. 3. Clients facing death may wish to find meaning and purpose in life through a higher power. This gives the clients hope, even if the life on earth will be temporary. 4. The nurse is not the expert but should be comfortable with his or her own beliefs to be able to allow the client to discuss personal beliefs and hopes. The experts would be chaplains and spiritual advisers from the client's faith. TEST-TAKING HINT: The test taker should recognize the nurse's expertise is not in the spiritual realm, although the nurse is frequently the one called on to perform the assessment and refer to the appropriate person. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 3

17. The client with chronic low back pain is having trouble sleeping at night. Which nonpharmacological therapy should the nurse teach the client? 1. Acupuncture. 2. Massage therapy. 3. Herbal remedies. 4. Progressive relaxation techniques. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

17. 1. Acupuncture is an alternative therapy, but a nurse cannot teach it and the client cannot do this to himself or herself. 2. A client cannot perform massage therapy on himself or herself. 3. The nurse should not prescribe herbal remedies. 4. Progressive relaxation techniques involve visualizing a specific muscle group and mentally relaxing each muscle; this can be taught to the client, and it will allow the client to relax, which will foster sleep. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 4

17. The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the female nurse implement at the time of death? 1. Allow the wife to stay in the room during postmortem care. 2. Call the client's imam to perform last rites when the client dies. 3. Place incense around the bed, but do not allow anyone to light it. 4. Do not touch the body, and have the male family members perform care. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

17. 1. No female is allowed to perform the postmortem care on a male Muslim client; this should be performed by a man. 2. Last rites are performed by a Catholic priest, not a Muslim imam. 3. Hindus use incense to pray, but Muslims do not. 4. Females, including the spouse, are not allowed to touch a male's body after death. The nurse should respect this and allow the male members of the family or mosque to perform postmortem care. TEST-TAKING HINT: The question is requiring culturally sensitive knowledge. The test taker must be aware of the different beliefs of the clients being cared for. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 4

18. The client diagnosed with cancer is unable to attain pain relief despite receiving large amounts of narcotic medications. Which intervention should be included in the plan of care? 1. Ask the HCP to increase the medication. 2. Assess for any spiritual distress. 3. Change the client's position every two (2) hours. 4. Turn on the radio to soothing music. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

18. 1. The client is already receiving large amounts of medication. The nurse should assess for other causes of pain. 2. Pain has many components, and spiritual distress or psychosocial needs will affect the client's perception of pain; remember, assessment is the first step of the nursing process. 3. Usually clients will naturally assume the most comfortable position, and forcing them to move may increase their pain. 4. The client may or may not like this type of music, but it would not be the first intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 2

A nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching? A. "I should avoid the use of a heating pad on my back." B. "To relieve the pressure on my hip, I can use a can while ambulating." C. "I have steroid injections to my joints as the first mediation of choice to treat my pain." D. "I will exercise even if it causes pain."

B. "To relieve the pressure on my hip, I can use a can while ambulating."

18. The nurse writes a client problem of "spiritual distress" for the client who is dying. Which statement is an appropriate goal? 1. The client will reconcile self and the higher power of his or her beliefs. 2. The client will be able to express anger at the terminal diagnosis. 3. The client will reconcile self to estranged members of the family. 4. The client will have a dignified and pain-free death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

18. 1. The primary goal of spiritual care is to allow the client to be able to reconcile himself or herself with a higher being, maybe God. This goal is based on the belief that life comes from God, and to some degree for many people the process of living includes some separation from God. In the Western world, 95% of the people claim some belief in God. 2. This could be a goal for a diagnosis of anger, but it does not recognize the spiritual aspect of the client. 3. This would be a goal for altered family functioning. 4. This is the physiological goal for any client who is dying, but it is not a goal for spiritual distress. TEST-TAKING HINT: The identified problem is "spiritual distress," and the goal must have information which addresses the spiritual. This would eliminate option "4." Personal relationships with family members (option "3") could also be eliminated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1

19. The client diagnosed with chronic pain is laughing and joking with visitors. When the nurse asks the client to rate the pain on a 1-to-10 scale, the client rates the pain as 10. According to the FACES® pain scale, how would the nurse chart the client's pain (See figure below)? 1. The client's pain is between a zero (0) and two (2) on the FACES® scale. 2. The client's pain is a "10" on a 1-to-10 pain scale. 3. The client is unable to accurately rate the pain on a scale. 4. The client's pain is moderate on the pain scale. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

19. 1. The Faces pain scale was devised to help children identify pain when they are unable to understand the concept of numbers. The nurse can use this pain scale when caring for adults who are unable to use the 1-to-10 numerical scale. This client rated the pain at a 10. 2. Pain is whatever the client says it is and occurs whenever the client says it does. Pain is a wholly subjective symptom, and the nurse should not question the client's perception of pain. The client's pain is a 10. 3. The client did rate the pain on the pain scale. Laughing and talking with visitors may occur with excruciating chronic pain. The client in chronic pain must learn to adapt to pain and try to live as normal a life as possible. 4. The client rated the pain at a 10. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 2

19. The hospice care nurse is planning the care of an elderly client diagnosed with end-stage renal disease. Which interventions should be included in the plan of care? Select all that apply. 1. Discuss financial concerns. 2. Assess any comorbid conditions. 3. Monitor increased visual or auditory abilities. 4. Note any spiritual distress. 5. Encourage euphoria at the time of death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

19. 1. The elderly are frequently on fixed incomes, and financial concerns are important for the nurse to address. A social services referral may be needed. 2. The elderly may have many comorbid conditions, which affect the type and amount of medications the client can tolerate and the client's quality of life. 3. Visual and auditory senses decrease with age; they do not increase. 4. The client may feel some spiritual distress at the terminal diagnosis. Even if the client possesses a strong faith, the unknown can be frightening. 5. A type of euphoria may accompany dehydration prior to death. This is a natural physiological occurrence the nurse should recognize, but it is not an intervention the nurse can implement. TEST-TAKING HINT: The test taker can decide on three (3) of the answer options based on the descriptive word "elderly." Option "5" is not a nursing intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1,2,4

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during his assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is likely experiencing: 1. Dementia 2. Depression 3. Delirium 4. Hypoglycemic reaction

2

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: 1. Call social services to begin nursing home placement 2. Ask the son to step out of the room so she can complete her assessment 3. Call adult protective services because you suspect elder mistreatment 4. Assess patient's cognitive status

2

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

2 Patients experience circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes.

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply) 1. Yell so the patient can hear you 2. Sit facing the patient so he is able to watch your lip movements and facial expressions 3. Present one idea or concept at a time 4. Send a written copy of the instructions home with him and tell him to have the family review them 5. Include the family caregiver in the teaching session

2 3 5

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLS include independence with: (Select all that apply) 1. Driving 2. Toileting 3. Bathing 4. Daily exercise 5. Eating

2 3 5

2. The primary nurse caring for the client who died is crying with the family at the bedside. Which action should the charge nurse implement? 1. Request the primary nurse to come out in the hall. 2. Refer the nurse to the employee assistance program. 3. Allow the nurse and family this time to grieve. 4. Ask the chaplain to relieve the nurse at the bedside. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

2. 1. The nurse is providing care for the family and should not have to leave the bedside. 2. An employee assistance program is available at many facilities for counseling employees who are having psychosocial issues, but this nurse is being humane. 3. Crying was once considered unprofessional, but today it is recognized as simply an expression of empathy and caring. 4. The chaplain may come to the client's room and offer support but should not relieve the nurse who has developed a therapeutic nurse- client relationship with the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 3

2. The nurse is presenting an in-service discussing do not resuscitate (DNR) orders and advance directives. Which statement should the nurse discuss with the class? 1. Advance directives must be notarized by a notary public. 2. The client must use an attorney to complete the advanced directive. 3. Once the DNR is written, it can be used for every hospital admission. 4. The health-care provider must write the DNR order in the client's chart. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

2. 1. This is not true; someone who is not family or directly involved in the client's care must witness the AD, but the document does not have to be notarized. 2. This form can be filled out without the use of an attorney; copies of an AD can be obtained at hospitals or online from various sources. 3. The DNR order must be written on each admission. 4. The HCP writes the DNR order in the client's chart, and the client completes the AD. TEST-TAKING HINT: Options "1" and "2" involve other legal entities outside the healthcare arena, which would make the test taker eliminate them. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 4

2. Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do? a. Assess their understanding of what hospice care services are. b. Ask them how they will care for the patient without hospice care. c. Talk directly to the patient and family to see if she can change their minds. d. Accept their decision since they are Hispanic and prefer to care for their own. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

2. a. The family may not understand what hospice care is and may need information. Some cultures and ethnic groups may underuse hospice care because of a lack of awareness of the services offered, a desire to continue with potentially curative therapies, and concerns about a lack of minority hospice workers. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

20. The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to: 1. Be treated with respect and dignity. 2. Have particulars of the death withheld. 3. Receive optimal and effective pain management. 4. Receive holistic and compassionate care. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

20. 1. The client has the right to be cared for with respect and dignity. 2. The client has the right to discuss his or her feelings and direct his or her care. Withholding information would be lying to the client. 3. The client has the right to the best care available and to have pain treated, regardless of the potential for hastening death. 4. All clients, even if they are not dying, have the right to holistic and compassionate care. TEST-TAKING HINT: This is an "except" question. All of the answer options except one have correct information. The test taker should read the stem carefully to recognize this type of question. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 2

20. The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and asks the nurse, "Which organs can I donate?" Which statement is the nurse's best response? 1. "It is wonderful you want to be an organ donor. Let's discuss this." 2. "You can donate any organ in your body, except the pancreas." 3. "You have to donate your body to science to be an organ donor." 4. "You cannot donate any organs, but you can donate some tissues." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

20. 1. This is not answering the client's question. 2. A client with type 2 diabetes has organ damage as a result of the high glucose over time; therefore, most organs are not usable. 3. This is a false statement. The client does not have to will his or her body to science to be a tissue/organ donor. 4. The client can donate corneas, skin, and some joints, but organ donation from clients with type 2 diabetes mellitus usually is not allowed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

21. The client is on the ventilator and has been declared brain dead. The spouse refuses to allow the ventilator to be discontinued. Which collaborative action by the nurse is most appropriate? 1. Discuss referral of the case to the ethics committee. 2. Pull the plug when the spouse is not in the room. 3. Ask the HCP to discuss the futile situation with the spouse. 4. Inform the spouse what is happening is cruel. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

21. 1. The nurse should discuss using the ethics committee with the HCP to assist the family in making the decision to terminate life support. Many families feel there may be a racial or financial reason the HCP wants to discontinue life support. 2. This would be an illegal act on the part of the nurse and would destroy the nurse-client relationship with the family. 3. The stem already indicates the spouse is aware of the situation. 4. This is expressing a personal bias on the part of the nurse. TEST-TAKING HINT: The test taker could eliminate option "2" based on the legal and ethical issues. Option "3" is asking the HCP to do something which has already been done. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1

21. The client with multiple sclerosis who is becoming very debilitated tells the home health nurse the Hemlock Society sent information on euthanasia. Which question should the nurse ask the client? 1. "Why did you get in touch with the Hemlock Society?" 2. "Did you know this is an illegal organization?" 3. "Who do you know who has committed suicide?" 4. "What religious beliefs do you practice?" Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

21. 1. The nurse should not ask the client "why" he or she does something; this is judgmental. 2. This answer option is giving erroneous information because it is not illegal; it is an organization which supports active euthanasia. 3. This question is not relevant to the situation. 4. This question must be asked because Judeo-Christian belief supports the view that suicide is a violation of natural law and the laws of God. The tenets of the Hemlock Society are in direct opposition to Judeo-Christian beliefs. If the client is agnostic, then this organization may be helpful to the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

22. The client has been in a persistent vegetative state for several years. The family, who have decided to withhold tube feedings because there is no hope of recovery, asks the nurse, "Will the death be painful?" Which intervention should the nurse implement? 1. Tell the family the death will be painful but the HCP can order medications. 2. Inform the family dehydration provides a type of natural euphoria. 3. Relate other cases where the clients have died in excruciating pain. 4. Ask the family why they are concerned because they want the client to die anyway. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

22. 1. Death from dehydration occurs when the client is unable to take in fluids, but dehydration is not painful. 2. Death from dehydration occurs when the client is unable to take in fluids. A natural euphoria occurs with dehydration. This is the body's way of allowing comfort at the time of death. 3. This is needless. 4. Families who make this decision usually do so from a deep sense of love and commitment. It is an extremely difficult decision to make, and the nurse should not condemn the family decision. TEST-TAKING HINT: The test taker could examine options "3" and "4" and eliminate them based on the needless information or the nurse stepping outside of professional boundaries. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 2

22. Which intervention should the nurse implement to provide culturally sensitive health care to the European-American Caucasian elderly client who is terminal? 1. Discuss health-care issues with the oldest male child. 2. Determine if the client will be cremated or have an earth burial. 3. Do not talk about death and dying in front of the client. 4. Encourage the client's autonomy and answer questions truthfully. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

22. 1. Many Middle Eastern cultures practice this, but the Caucasian culture does not. 2. Caucasians as a culture do not necessarily have a preference, but this does not affect culturally sensitive health care. 3. Frequently Caucasians do not like to talk about death and dying, but this is an individual preference of the client and the nurse should allow the discussion. 4. The western Caucasian society values autonomy and truth telling in individual decision making. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

23. Which action by the primary nurse would require the unit manager to intervene? 1. The nurse uses a correction fluid to correct a charting mistake. 2. The nurse is shredding the worksheet at the end of the shift. 3. The nurse circles an omitted medication time on the MAR. 4. The nurse documents narcotic wastage with another nurse. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

23. 1. The client's chart is a legal document, and if a mistake occurs, it should be corrected by marking one line through the entry in such a way the entry can still be read in a court of law. Erasing, using a correction fluid, or obliterating the entry is illegal. 2. This is the correct method for disposing of any paper which has client information on it which is not a part of the client's permanent medical record. 3. This is the correct method to indicate a medication was not administered to the client; the circle means the person should go to the nurse's notes to read the reason why the medication was not administered. 4. All narcotics not administered to the client must be verified when being wasted and then documented. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 1

What are the most common life events that occur during young adulthood? (Select all that apply.) a. Refining self-perception and ability for intimacy b. Achievement and mastery of the surrounding world c. Examination of life goals and relationships d. Rejection of culture-bound definitions of health and illness e. Women surrendering careers to raise families

A, B, C

23. The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process? 1. How angry are the family members about the death? 2. Which family member will be making decisions? 3. What previous coping skills have been used? 4. What type of funeral service has been planned? Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

23. 1. The family may or may not be angry and this would need to be addressed, but it is not the most important. 2. Who makes the decisions is not as important as discovering which coping skills the family uses when under stress. 3. The nurse should assess previous coping skills used by the family and build on those to assist the family in dealing with their loss. Coping mechanisms are learned behaviors and should be supported if they are healthy behaviors. If the client and family use unhealthy coping behaviors, then the nurse should attempt to guide the family to a counselor or support group. 4. The type of funeral service may help the family to grieve, but it is not the most important intervention. TEST-TAKING HINT: The test taker must prioritize the interventions listed. All of the interventions could be addressed in option "3." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 3

24. The client who is terminally ill called the significant others to the room and said goodbye, then dismissed them and now lies quietly and refuses to eat. The nurse understands the client is in what stage of the grieving process? 1. Denial. 2. Anger. 3. Bargaining. 4. Acceptance. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

24. 1. The client is not denying death; the client has said good-bye. 2. Anger is the second stage of the grieving process, but this client appears to have accepted death. 3. There is no evidence of bargaining in the client's actions. 4. The client has accepted the imminent death and is withdrawing from the significant others. TEST-TAKING HINT: There are five (5) stages to Dr. Elisabeth Kübler-Ross's grieving process, and some authorities list several more, but this behavior could only be withdrawal or acceptance. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 4

24. Which action should the nurse implement for the Chinese client's family who are requesting to light incense around the dying client? 1. Suggest the family bring potpourri instead of incense. 2. Tell the client the door must be shut at all times. 3. Inform the family the scent will make the client nauseated. 4. Explain the fire code does not allow any burning in a hospital. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

24. 1. The nurse must support the client's culture. Potpourri provides the scent without having the burning incense, which is against fire code, and thus is a compromise which supports the client's culture. 2. Having the door shut does not matter; open flames are not allowed in any health-care facility. 3. This is not necessarily true, and if it is part of the cultural beliefs about dying, then the nurse should medicate the client if he or she becomes nauseated. 4. This is a fact, but the nurse should attempt to compromise and support the client and family's cultural needs, especially at the time of death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition. 1

25. The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe? 1. The client's blood pressure is elevated. 2. The client has rapid shallow respirations. 3. The client has facial grimacing. 4. The client is lying quietly in bed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

25. 1. Blood pressure elevates in acute pain. Chronic pain, by definition, lasts more than six (6) months, lasts far beyond the expected time for the pain to resolve, and may have an unclear onset. Changes in vital signs result from the fight-or-flight response by the body. The body cannot maintain this response and must adjust. 2. Rapid shallow respirations might be attributed to acute pain if it was painful to breathe. The client with a chest injury or pain will splint the area and slow the respirations or attempt to breathe shallowly and rapidly. 3. Facial grimacing will occur in acute pain and is an objective sign the nurse can identify. Clients with chronic pain may be laughing and still be in pain. Remember, pain is whatever the client says it is and occurs whenever the client says it does. 4. The client in chronic pain will have adapted to living with the pain, and lying quietly may be the best way for the client to limit the feeling of pain. TEST-TAKING HINT: The test taker must be able to differentiate between acute and chronic pain. Options "1," "2," and "3" are objective symptoms of acute pain. If the test taker were aware of this, then choosing the only option left would be a good choice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 4

25. The nurse is caring for the client who has active tuberculosis of the lungs. The client does not have a DNR order. The client experiences a cardiac arrest, and there is no resuscitation mask at the bedside. The nurse waits for the crash cart before beginning resuscitation. According to the ANA Code of Ethics for Nurses (see Table 18-1), which disciplinary action should be taken against the nurse? 1. Report the action to the State Board of Nurse Examiners. 2. The nurse should be terminated for failure to perform duties. 3. No disciplinary action should be taken against the nurse. 4. Refer the nurse to the American Nurses Association. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

25. 1. There is no need to report this action to the state board; this is not malpractice. 2. This action does not warrant the nurse being terminated. 3. The Code states, "The nurse owes the same duty to self as to others, including the responsibility to preserve integrity and safety." Therefore, if the nurse realizes he or she could contract TB if unprotected mouth-to-mouth resuscitation is performed, then not doing this action does not violate the Code of Ethics. 4. The ANA cannot discipline nurses; it is a voluntary nurse's organization. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition. 3

26. The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement? 1. Have the client see a psychologist because the pain is not real. 2. Tell the client the pain is the cancer coming back. 3. Refer the client to a physical therapist to prevent a frozen shoulder. 4. Discuss changing the client to a more potent narcotic medication. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

26. 1. Pain is whatever the client says it is and occurs whenever the client says it does. The nurse should never deny the client's pain exists. 2. This has been occurring for the past three (3) years and does not mean the cancer has come back. Many clients will fear the cancer has recurred and delay treatment; denial is a potent coping mechanism. 3. PMP is characterized as a constriction accompanied by a burning sensation or prickling in the chest wall, axilla, or posterior arm resulting from movement of the arm. Because of this, the client limits movement of the arm and the shoulder becomes frozen. 4. There are many problems associated with long-term narcotic use. Other strategies should be attempted prior to resigning the client to a lifetime of taking narcotic medications. TEST-TAKING HINT: The test taker could eliminate option "1" because it violates all principles of pain management. Option "2" is not in the realm of the nurse's responsibility. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 3

26. The wife of a client receiving hospice care being cared for at home calls the nurse to report the client is restless and agitated. Which interventions should the nurse implement? List in order of priority. 1. Request an order from the health-care provider for antianxiety medications. 2. Call the medical equipment company and request oxygen for the client. 3. Go to the home and assess the client and address the wife's concerns. 4. Reassure and calm the wife over the telephone. 5. Notify the chaplain about the client's change in status. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

26. In order of priority: 4, 3, 2, 1, 5. 4. The nurse should calm and reassure the wife over the telephone. 3. The nurse should then visit the client immediately to assess the change in condition. 2. Restlessness and agitation are symptoms of lack of oxygen. Therefore, calling the medical equipment company to send oxygen would be the next intervention. 1. Terminal restlessness is difficult for the family to watch and the client to experience, so antianxiety medications would be the next logical intervention. 5. Referral to the chaplain is needed because death may be imminent. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition.

27. The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, "What good will it do? I will never be free of this pain." Which statement is the nurse's best response? 1. "Are you afraid of the pain never going away?" 2. "The pain clinic will give you medication to cure the pain." 3. "Pain clinics work to help you achieve relief from pain." 4. "I am not sure. You should discuss this with your HCP." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

27. 1. This is a therapeutic response and the client is requesting information. 2. Pain clinics do not cure pain; they do help identify measures to relieve pain. 3. Pain clinics use a variety of methods to help the client to achieve relief from pain. Some measures include guided imagery, transcutaneous electrical nerve stimulation (TENS) units, nerve block surgery or injections, or medications. 4. This is not an appropriate answer, even if the nurse is not sure. The nurse should attempt to discover the information for the client and then give factual information. TEST-TAKING HINT: The test taker should answer a question with factual information. If the stem asks for a therapeutic response, then the test taker should choose one which addresses feelings. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 3

28. The client diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain? 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain. 2. Morphine sustained release, a narcotic, routinely with a liquid morphine preparation for breakthrough pain. 3. Extra-Strength Tylenol, a nonnarcotic analgesic, plus therapy to learn alternative methods of pain control. 4. Demerol, an opioid narcotic, every six (6) hours orally with a suppository when the pain is not controlled. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

28. 1. NSAIDs around the clock are dangerous because of the potential for gastrointestinal ulceration. NSAIDs are not the drug of choice for cancer pain. 2. Morphine is the drug of choice for cancer pain. There is no ceiling effect, it metabolizes without harmful by-products, and it is relatively inexpensive. A sustainedrelease formulation, such as MS Contin, is administered every six (6) to eight (8) hours, and a liquid fast-acting form is administered sublingually for any pain which is not controlled. 3. Tylenol is not strong enough for this client's pain. The maximum adult dose within a 24-hour period is four (4) g. Tylenol is toxic to the liver in higher amounts. 4. Meperidine (Demerol) metabolizes into normeperidine and is not cleared by the body rapidly. A buildup of normeperidine can cause the client to seize. TEST-TAKING HINT: The test taker must be aware of medications and their uses. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 2

The nurse provides postmortem care for a client who is not undergoing an autopsy. To achieve the desired outcome of this procedure, which nursing actions should be included? (Select all that apply.) a) Place an identification tag on the client's ankle b) Provide emotional support to the client's family c) Ensure the death certificate has been signed d) Remove any tubes and replace soiled dressings e) Wash the client's body with soap and water

A, B, C, D

A nurse is collecting data from an older adult client. Which of the following actions should the nurse take to collect subjective data? A. Leave the client a written questionnaire to fill out in private B. Allow sufficient time for the client to respond to the questions C. Talk to family members to obtain the client's health history D. Obtain the health history from the client's medical record

B. Allow sufficient time for the client to respond to the questions

29. The client is being discharged from the hospital for intractable pain secondary to cancer and is prescribed morphine, a narcotic. Which statement indicates the client understands the discharge instructions? 1. "I will be sure to have my prescriptions filled before any holiday." 2. "There should not be a problem having the prescriptions filled anytime." 3. "If I run out of medications, I can call the HCP to phone in a prescription." 4. "There are no side effects to morphine I should be concerned about." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

29. 1. Narcotic medications require handwritten prescription forms (Drug Enforcement Agency rules) which must be filled within a limited time frame from the time the prescription is written. Many local pharmacies will not have the medication available or may not have it in the quantities needed. The client should anticipate the needs prior to any time when the HCP may not be available or the pharmacy may be closed. 2. There can be several reasons a legitimate prescription is not filled. 3. Morphine needs a handwritten prescription on a triplicate form. 4. All medications have side effects; most notably, narcotics slow peristalsis and cause constipation. TEST-TAKING HINT: The test taker could eliminate both options "1" and "2" because they are opposites. Option "4" is untrue of all medications. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 1

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more touch with time, place, and person. Which intervention will likely be most effective? 1. Reminiscence 2. Validation therapy 3. Reality orientation 4. Body image interventions

3

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at her home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her homework. The nurse suspects that the woman may have: 1. Presbyopia 2. Presbycusis 3. Cataract(s) 4. Depression

3

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

3 A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs.

A 50-year-old woman has elevated cholesterol profile values that increase her cardiovascular risk factor. One method to control this risk factor is to identify current diet trends and describe dietary changes to reduce the risk. This nursing activity is a form of: 1 Referral. 2 Counseling. 3 Health education 4 Stress management techniques.

3.

The nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to: 1 Instructing him to return in 2 years. 2 Instructing him in secondary prevention. 3 Instructing him in health promotion activities. 4 Implementing primary prevention with vaccines.

3.

When determining the amount of information that a patient needs to make decisions about the prescribed course of therapy, many factors affect the patient's compliance with the regimen, including educational level and socioeconomic factors. Which additional factor affects compliance? 1 Gender 2 Lifestyle 3 Motivation 4 Family history

3.

3. In which client situation would the AD be consulted and used in decision making? 1. The client diagnosed with Guillain-Barré who is on a ventilator. 2. The client with a C6 spinal cord injury in the rehabilitation unit. 3. The client in end-stage renal disease who is in a comatose state. 4. The client diagnosed with cancer who has Down syndrome. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

3. 1. A client diagnosed with Guillain-Barré syndrome is mentally competent, and being on a ventilator does not indicate the client has lost his or her decision-making capacity. 2. A client in the rehabilitation unit would be alert, and spinal cord injuries do not cause the client to lose decision-making capacity. 3. The client must have lost decision-making capacity as a result of a condition which is not reversible or must be in a condition specified under state law, such as a terminal, persistent vegetative state; an irreversible coma; or as specified in the AD. 4. A client with Down syndrome may have some mental challenges, but unless the client has been declared legally incompetent in a court of law, the client can complete an AD and participate in his/her own case. TEST-TAKING HINT: If the test taker knows what an AD is, then the words "end-stage" and "comatose" would lead the test taker to select option "3" as a correct answer. Remember, clients with congenital or genetic disorders are not incompetent, even if they are mentally challenged. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 3

33. The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients in a pain clinic. Which intervention would be inappropriate to delegate to the UAP? 1. Assist the client diagnosed with intractable pain to the bathroom. 2. Elevate the head of the bed for a client diagnosed with back pain. 3. Perform passive range of motion for a client who is bedfast. 4. Monitor the potassium levels on a client about to receive medication. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

33. 1. The UAP could perform this function. 2. The UAP could perform this function. 3. The UAP could perform this function. 4. The nurse should monitor any laboratory work needed to administer a medication safely. TEST-TAKING HINT: The rules for delegation state assessment, teaching, evaluating, or anything requiring nursing judgment cannot be delegated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 4

3. The nurse is discussing advance directives with the client. The client asks the nurse, "Why is this so important to do?" Which statement would be the nurse's best response? 1. "The federal government mandates this form must be completed by you." 2. "This will make sure your family does what you want them to do." 3. "Don't you think it is important to let everyone know your final wishes?" 4. "Because of technology, there are many options for end-of-life care." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

3. 1. Advance directives (AD) are not mandated by the federal government. The nurse must discuss this with the client, but the client does not have to complete it. 2. ADs can be overridden by the family because the health-care provider is worried about being sued by family survivors. 3. This response is not answering the client's question and it is argumentative. 4. Technology now allows for the body to maintain life functions indefinitely in some futile situations. ADs allow clients to make decisions, which hopefully will be honored at the time of their death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 4

3. List the two criteria for admission to a hospice program. a. b. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

3. a. Patient must desire services and agree in writing that only hospice care can be used to treat the terminal illness (palliative care) b. Patient must meet eligibility, which is less than 6 months to live, certified initially by two physicians Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

30. The client diagnosed with intractable pain is receiving an IV constant infusion of morphine, a narcotic opioid. The concentration is 50 mg of morphine in 250 mL of normal saline. The IV is infusing at 10 mL/hr. The client has required bolus administration of two (2) mg IVP × two (2) during the 12-hour shift. How much morphine has the client received during the shift? _________ Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

30. 28 mg of morphine. First, determine how many milligrams of morphine are in each milliliter of saline: 50 ÷ 250 mL = 0.2 mg/mL Then determine how many milliliters are given in a shift: 10 mL/hr × 12 hour = 120 mL infused 1 shift = 120 mL infused If each milliliter contains 0.2 milligram of morphine, then 0.2 mg × 120 mL = 24 mg by constant infusion Then determine the amount given IVP: 2 × 2 = 4 mg given IVP Finally, add the bolus amount to the amount constantly infused: 24 + 4 = 28 mg TEST-TAKING HINT: The nurse is responsible for being knowledgeable of all medications and the amount the client is receiving. The test taker can use the drop-down calculator on the NCLEX-RN examination or ask the examiner for scratch paper. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition.

31. The male client who has made himself a do not resuscitate (DNR) order is in pain. The client's vital signs are P 88, R 8, and BP 108/70. Which intervention should be the nurse's priority action? 1. Refuse to give the medication because it could kill the client. 2. Administer the medication as ordered and assess for relief from pain. 3. Wait until the client' respirations improve and then administer the medication. 4. Notify the HCP the client is unstable and pain medication is being held. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

31. 1. The client is in pain and has the right to have pain-control measures taken. 2. The client is in pain. The American Nurses Association Code of Ethics states clients have the right to die as comfortably as possible even if the measures used to control the pain indirectly hasten the impending death. The Dying Client's Bill of Rights reiterates this position. The client should be allowed to die with dignity and with as much comfort as the nurse can provide. 3. The client may be splinting to prevent the pain from being too severe. The client's respirations actually may improve when the nurse administers the pain medication. 4. The HCP is aware the client is unstable because the HCP must write the DNR order on the chart. There is no reason to withhold needed medication. TEST-TAKING HINT: The position of administering medication which could hasten a client's death is a difficult one and requires the nurse to be aware of ethical position statements. Nurses never administer medications for the purpose of hastening death but sometimes must administer medications to provide what nurses do best, comfort. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 2

32. The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL. 2. The client diagnosed with lung cancer with a pulse oximeter reading of 89%. 3. The client diagnosed with colon cancer who needs the colostomy irrigated. 4. The client diagnosed with Kaposi's sarcoma who is yelling at the staff. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

32. 1. This hemoglobin is low but would be expected for a client diagnosed with leukemia. A less experienced nurse could care for this client. Leukemia affects production of all cells produced by the bone marrow—either there is too much production of immature cells overpowering the ability of the bone marrow to use the pluripotent cells to produce other needed blood cells or because the bone marrow is not producing enough cells as needed. It effectively produces a pancytopenia. 2. This represents an arterial blood gas of less than 60%; this client should be assigned to the most experienced nurse. 3. A client who needs a colostomy irrigated could be assigned to a less experienced nurse. 4. Psychological problems come second to physiological ones. TEST-TAKING HINT: This is a priority question. The test taker should realize option "1" is expected and may even be good for this client; option "3" is expected and not life threatening; and option "4," although not expected, is not life threatening. By doing this, the test taker could then look at what was determined for each option and realize option "2" needs the most experienced nurse. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 2

A nurse us contributing to the plan of care for a client who had a recent stroke and a history of gastroesophageal reflux disease (GERD). For which of the following disorders should the nurse plan to monitor this client? A. Duodenal ulcer disease B. Aspiration pneumonia C. Viral pneumonia D. Esophageal varices

B. Aspiration pneumonia

34. The client diagnosed with chronic back pain is being placed on a transcutaneous electrical nerve stimulation (TENS) unit. Which information should the nurse teach? 1. The TENS unit will deaden the nerve endings, and the client will not feel pain. 2. The TENS unit could cause paralysis if the client gets the unit wet. 3. The TENS unit stimulates the nerves in the area, blocking the pain sensation. 4. The TENS unit should be left on for an hour, and then taken off for an hour. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

34. 1. The TENS unit does not deaden nerve endings; this would be accomplished through local anesthesia. 2. The unit could stop functioning if it got wet, but this would not cause paralysis. 3. The TENS unit works on the gate control theory of pain control and works by flooding the area with stimulation and blocking the pain impulses from reaching the brain. 4. The TENS unit should be applied and left in place unless the client is showering. TEST-TAKING HINT: A medical device which causes paralysis so easily would not be approved for use by the general population, so option "2" could be eliminated. The test taker would need to be aware of the gate control theory of pain control to eliminate the other options. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 3

35. The nurse is caring for clients on a medical floor. Which client should the nurse assess first after the shift report? 1. The client with arterial blood gases of pH 7.36, Paco2 40, HCO3 26, Pao2 90. 2. The client with vital signs of T 99˚F, P 101, R 28, and BP 120/80. 3. The client complaining of pain at a "10" on a 1-to-10 scale who can't localize it. 4. The client who is postappendectomy with pain at a "3" on a 1-to-10 scale. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

35. 1. These are normal arterial blood gases. 2. These temperature, pulse, and respiration rates are only slightly elevated, and the blood pressure is normal. 3. This is typical of clients with chronic pain. They cannot localize the pain and frequently describe the pain as always being there, as disturbing rest, and as demoralizing. This client should be seen, and appropriate pain-control measures should be taken. 4. This is considered mild pain, and this client can be seen after the client in chronic pain. TEST-TAKING HINT: Options "1" and "2" could be eliminated because the values are within normal limits or only slightly above normal. Option "4" could be eliminated because three (3) is low on the 1-to-10 pain scale. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 3

36. The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first? 1. Tell the client it is important for her to take her medication. 2. Find out how the client has been dealing with the pain. 3. Have the HCP tell the client to take the pain medications. 4. Instruct the client not to worry—the pain will resolve itself. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

36. 1. This could be appropriate once the nurse assesses the situation further. 2. The nurse should assess the situation fully. The client may be afraid of becoming addicted or may have been using alternative forms of treatment, such as music therapy, distraction techniques, acupuncture, or guided imagery. 3. This is not appropriate. It is in the nurse's realm of responsibility to investigate the client's reasons for not wanting to take pain medication. 4. Chronic cancer pain does not resolve on its own. TEST-TAKING HINT: Option "1" is advising without assessing. Assessment is the first step of the nursing process and should be implemented first in most situations unless a direct intervention treats the client in an emergency. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 2

37. The nurse is teaching an in-service on legal issues in nursing. Which situation is an example of battery, an intentional tort? 1. The nurse threatens the client who is refusing to take a hypnotic medication. 2. The nurse forcibly inserts a Foley catheter in a client who refused it. 3. The nurse tells the client a nasogastric tube insertion is not painful. 4. The nurse gives confidential information over the telephone. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

37. 1. This is an example of assault, which is a mental or physical threat without touching the client. 2. When a mentally competent adult is forced to have a treatment he or she has refused, battery occurs. 3. This is fraud, a willful and purposeful misrepresentation which could cause harm to a client. 4. This is called defamation, a divulgence of privileged information or communication. This is a violation of the Health Insurance Portability and Accountability Act (HIPAA). TEST-TAKING HINT: If the test taker knows battery is "bad," it may lead to selecting option "2," which has "forcibly" in the stem. The test taker could attempt to eliminate options based on knowledge. For example, breaking confidentiality is a violation of HIPAA; thus option "4" can be eliminated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 2

38. Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care? 1. The Health Insurance Portability and Accountability Act. 2. The State Nurse Practice Act. 3. The Emergency Rendering Aid Act. 4. The Good Samaritan Act. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

38. 1. The Health Insurance Portability and Accountability Act (HIPAA) is a federal act protecting the client's privacy while receiving health care. 2. The state Nurse Practice Acts provides the laws which control the practice of nursing in each state. 3. There is no such law as this act. 4. The Good Samaritan Act protects healthcare practitioners against malpractice claims for care provided in emergency situations. TEST-TAKING HINT: The test taker should be knowledgeable of the Good Samaritan Act and its implications in the nurse's professional career. The NCLEX-RN often asks questions on this act. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 4

39. The family has requested a client with terminal cancer not be told of the diagnosis. The client tells the nurse, "I think something is really wrong with me, but the doctor says everything is all right. Do you know if there is something wrong with me?" Which response by the nurse would support the ethical principle of veracity? 1. "I think you should talk to your doctor about your concerns." 2. "What makes you think something is really wrong?" 3. "Your family has requested you not be told your diagnosis." 4. "The doctor would never tell you incorrect information." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

39. 1. This response does not support veracity. 2. This response does not support veracity. 3. The principle of veracity is the duty to tell the truth. This response is telling the client the truth. 4. This response does not support veracity. TEST-TAKING HINT: The test taker must know certain ethical principles, such as veracity, beneficence, nonmalfeasance, fidelity, autonomy, and justice, to name a few. Without knowing the definition of veracity, the test taker would not be able to answer this question correctly. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 3

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased 2. The sexual preferences of older adults are not as diverse 3. Physical changes usually do not affect sexual functioning 4. Frequency and opportunities for sexual activity may decline

4

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? 1. When the sexual partner passes away, the survivor no longer feels sexual 2. A decrease in an older adult's libido occurs 3. Any outward expression of sexuality suggests that the older adult is having a development problem 4. All older adults, whether healthy or frail, need to express sexual feelings

4

The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? 1. Dementia 2. Elder abuse 3. Delirium 4. Alcohol abuse

4

A 34-year-old female executive has a job with frequent deadlines. She notes that, when the deadlines appear, she has a tendency to eat high-fat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. The nurse provides a number of options for the executive, and she chooses yoga. In this scenario yoga is used as a(n): 1 Outpatient referral. 2 Counseling technique. 3 Health promotion activity. 4 Stress-management technique.

4.

A nurse who has recently graduated has been assigned to be a primary nurse of a geriatric unit. After completing a review of development and aging, the nurse recalls that changes for the older adult include 1 A transition from young adulthood 2 The ability of the older adult to achieve sexual arousal 3 A time when cognitive performance beings to peak 4 Adjusting to decreasing health and physical strengths

4.

A patient is laboring with her first baby, which is coming 2 weeks early. Her husband is in the military and might not get back in time, and both families are unable to be with her during labor. The doctor decides to call in which of the following people employed by the birthing area to be a support person to be present during labor? 1 Nurse 2 Midwife 3 Assistant 4 Lay doula

4.

Sharing eating utensils with a person who has a contagious illness increases the risk of illness. This type of health risk arises from: 1 Lifestyle. 2 Community. 3 Family history. 4 Personal hygiene habits.

4.

Which of the following might be a cause of stress for the older adult? 1 Financial security 2 Planned retirement 3 Maintaining satisfactory living environment 4 Adjusting to decreasing health and physical strength

4.

4. The nurse is moving to another state which is part of the multistate licensure compact. Which information regarding ADs should the nurse be aware of when practicing nursing in other states? 1. The laws regarding ADs are the same in all the states. 2. Advance directives can be transferred from state to state. 3. A significant other can sign a loved one's advance directive. 4. Advance directives are state regulated, not federally regulated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

4. 1. Individual states are responsible for specific legal requirements for ADs. 2. Moving from one state to another does not nullify or honor the AD; the nurse must be aware of the individual state's requirements. 3. Only the individual can complete and sign an AD. The significant other may be asked to implement the AD. 4. The state determines the definition of terms and requirements for an AD; individual states are responsible for specific legal requirements for ADs. TEST-TAKING HINT: The test taker should know the registered nurse must obtain a copy of the Nurse Practice Act of the state he or she is practicing in. The test taker should realize every state has different regulations regarding ADs and other health-care issues. Option "4" is the only option which reflects this thought. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 4

42. The client receiving dialysis for end-stage renal disease wants to quit dialysis and die. Which ethical principle supports the client's right to die? 1. Autonomy. 2. Self-determination. 3. Beneficence. 4. Justice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

42. 1. Autonomy implies the client has the right to make choices and decisions about his or her own care even if it may result in death or is not in agreement with the healthcare team. 2. Self-determination is not an ethical principle. 3. Beneficence is the duty to actively do good for clients. 4. Justice is the duty to treat all clients fairly. TEST-TAKING HINT: The test taker should be aware of ethical principles which mandate a nurse's behavior. Clients have rights, and autonomy is an important principle which the nurse must ensure every client has. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 1

4. The client who is of the Jewish faith died during the night. The nurse notified the family, who do not want to come to the hospital. Which intervention should the nurse implement to address the family's behavior? 1. Take no further action because this is an accepted cultural practice. 2. Notify the hospital supervisor and report the situation immediately. 3. Call the local synagogue and request the rabbi go to the family's home. 4. Assume the family does not care about the client and follow hospital protocol. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

4. 1. Many of the Jewish faith do not believe in viewing or touching the dead body. The body is sent to the funeral home for burial within 24 hours, and a closed casket is preferred. 2. The hospital supervisor does not need to be notified the family did not want to come to the hospital. 3. The nurse needs to take care of the client, not the family, and should not call to request a rabbi to go visit the family. 4. The nurse must be aware of cultural differences and not be judgmental. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 1

4. For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death. Respiratory a. b. c. Skin a. b. c. Gastrointestinal a. b. c. Musculoskeletal a. b. c. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

4. Respiratory a. Cheyne-Stokes respiration b. Death rattle (inability to cough and clear secretions) c. Increased, then slowing, respiratory rate (Also: irregular breathing, terminal gasping) Skin a. Mottling on hands, feet, and legs that progresses to the torso b. Cold, clammy skin c. Cyanosis on nose, nail beds, and knees (Also: waxlike skin when very near death) Gastrointestinal a. Slowing of the gastrointestinal tract with accumulation of gas and abdominal distention b. Loss of sphincter control with incontinence c. Bowel movement before imminent death or at time of death Musculoskeletal a. Loss of muscle tone with sagging jaw b. Difficulty speaking c. Difficulty swallowing (Also: loss of ability to move or maintain body position, loss of gag reflex) Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1 C (98.8 F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2 C (99 F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? 1. Tell the student that temporary confusion is normal and simply requires reorientation 2. Tell the student to increase the patient's fluid intake since the urine is concentrated 3. Tell the student that her assessment findings are normal for an older adult 4. Tell the student that he will notify the patient's health care provider of the findings and recommended a urine culture

4. Tell the student that he will notify the patient's health care provider of the findings and recommended a urine culture

40. The nurse is obtaining the client's signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first? 1. Notify the client's surgeon. 2. Document the information in the chart. 3. Contact the operating room staff. 4. Explain the procedure to the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

40. 1. The surgeon is responsible for explaining the surgical procedure to the client; therefore, the nurse should first notify the surgeon. 2. This information should be documented on the chart, but it is not the first intervention. 3. The operating room staff may or may not need to be notified based on when or if the permit is being signed, but it is not the first intervention. 4. The nurse is not responsible for explaining the surgical procedure. The nurse is responsible for making sure the client understands and for obtaining the consent. TEST-TAKING HINT: The nurse is responsible for getting the permit signed and on the chart prior to going to surgery, but the nurse is not responsible for explaining the procedure to the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 1

41. The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights? 1. The nurse tells the client civilian clothes can be worn on the unit. 2. The nurse allows the client to have family visits during visiting hours. 3. The nurse delivers unopened mail and packages to the client. 4. The nurse listens to the client talking on the telephone to a friend. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

41. 1. Wearing their own clothes, keeping personal items, and having a small amount of money are civil rights of clients in a psychiatric unit. 2. Seeing visitors is a civil right of the client. 3. Receiving and sending unopened mail is a civil right of the client, but any packages must be inspected when the client is opening them to check for sharp items, weapons, or any type of medications. 4. This is a violation of the client's rights. The client has a right to have reasonable access to a telephone and the opportunity to have private conversations by telephone. TEST-TAKING HINT: The test taker must be aware of the client's legal and civil rights. The client in the psychiatric unit has the same rights as the client in the medical unit. Clients in a psychiatric hospital do not have to wear hospital gowns; they can wear their own clothes. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 4

43. Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior? 1. The Hippocratic Oath. 2. The Nuremberg Code. 3. Home Health Care Bill of Rights. 4. ANA Code of Ethics. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

43. 1. The Hippocratic Oath is the oath taken by medical doctors. 2. The Nuremberg Code identifies the need for voluntary informed consent when medical experiments are conducted on human beings. This source does not provide direction for the nurse addressing ethical issues. 3. This document informs clients and families receiving home health care of the ethical conduct they can expect from home care agencies and their employees when they are in the home. This source is not the best professional source for all nurses. 4. The American Nurses Association (ANA) Code of Ethics outlines to society the values, concerns, and goals of the nursing profession. The code provides direction for ethical decisions and behavior by emphasizing the obligations and responsibilities which are entailed in the nurse-client relationship. TEST-TAKING HINT: The test taker must be aware of the word "best" to be able to answer this question. All four (4) answer options may or may not be potential answers, but the test taker must select the option which addresses all nurses. Option "3" should be eliminated as a possible answer because it only addresses home health care. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 4

44. Which element is not necessary to prove nursing malpractice? 1. Breach of duty. 2. Identify the ethical issues. 3. Injury to the client. 4. Proximate cause. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

44. 1. Breach of duty is one (1) of the four (4) elements necessary to prove nursing malpractice. It is failure to perform according to the established standard of conduct. 2. This is one (1) of the four (4) steps in ethical decision making. It is not one (1) of the four (4) elements necessary to prove nursing malpractice. 3. Failure to meet the standard of care resulting in an actual injury or damage to the client is required to prove nursing malpractice. 4. A connection must exist between conduct and the resulting injury to prove nursing malpractice. TEST-TAKING HINT: This is a knowledge-based question, but the test taker should realize ethical issues and legal issues are two different concerns and that malpractice is a legal concern. The test taker should also know the four (4) elements necessary to prove nursing malpractice: (1) The nurse has a duty to the client. (2) The duty has been breached. The nurse failed to uphold a standard of care. (3) There is some harm to the client. (4) The breach of duty caused the harm. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 2

45. The nurse is caring for a client who is confused and fell trying to get out of bed. There is no family at the client's bedside. Which action should the nurse implement first? 1. Contact a family member to come and stay with the client. 2. Administer a sedative medication to the client. 3. Place the client in a chair with a sheet tied around him or her. 4. Notify the health-care provider to obtain a restraint order. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

45. 1. This action should be taken, but this is not the first action to keep the client safe. 2. This is a form of chemical restraint, and the nurse must have a health-care provider's order. 3. This is a form of restraint and is against the law unless the nurse has a health-care provider's order. 4. The nurse must notify the health-care provider before putting the client in restraints. Restraints are used in an emergency situation and for a limited time and must be for the protection of the client. TEST-TAKING HINT: The test taker must realize when the stem asks which action is first; more than one option may be appropriate for the situation, but only one is implemented first. Restraining a client is considered battery and is against the law unless the client is a danger to self and there is a health-care provider's order. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 4

46. Which entity mandates the registered nurse's behavior when practicing professional nursing? 1. The state's Nurse Practice Act. 2. Client's Bill of Rights. 3. The United States legislature. 4. American Nurses Association. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

46. 1. Nurse Practice Acts provide the laws which control the practice of nursing in each state. All states have Nurse Practice Acts. 2. The Client's Bill of Rights, also known as "Your Rights as a Hospital Patient," is a document which explains the client's rights to participate in his or her own health care; it does not address the nurse's behavior. 3. Each state, not the U.S. Congress, is responsible for writing and implementing the state's Nurse Practice Act. 4. The American Nurses Association is a voluntary organization which provides standards of care and a code of ethics. It addresses issues in nursing, but it does not mandate the registered nurse's behavior. TEST-TAKING HINT: This is a knowledgebased question which the test taker must know. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 1

47. The nurse must be knowledgeable of ethical principles. Which is an example of the ethical principle of justice? 1. The nurse administers a placebo, and the client asks if it will help the pain. 2. The nurse accepts a work assignment in an area in which he or she is not experienced. 3. The nurse refuses to tell a family member the client has a positive HIV test. 4. The nurse provides an indigent client with safe and appropriate nursing care. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

47. 1. This addresses the ethical principle of veracity. Should the nurse tell the client truthfully a placebo will not help the pain? 2. This is an example of nonmalfeasance, the duty to prevent or avoid doing harm, whether intentional or unintentional. Is it harmful for a nurse to work in an area where he or she is not experienced? 3. This is an example of the ethical principle of fidelity, the duty to be faithful to commitments. It involves keeping promises and information confidential and maintaining privacy. 4. Justice involves the duty to treat all clients fairly, without regard to age, socioeconomic status, or any other variables. Providing safe and appropriate nursing care to all clients is an example of justice. TEST-TAKING HINT: The test taker must be knowledgeable of ethical principles; they are part of the NCLEX-RN blueprint. The word "justice" should make the test taker think about fairness, which might lead the test taker to select option "4" as the correct answer. The test taker should not automatically think, "I don't know the answer." Think about the words before selecting the correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 4

48. The nurse is discussing malpractice issues in an in-service class. Which situation is an example of malpractice? 1. The nurse fails to report a neighbor who is abusing his two children. 2. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122. 3. The nurse is suspected of taking narcotics prescribed for a client. 4. The nurse falsifies vital signs in the client's medical records. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition. 48. The nurse is discussing malpractice issues in an in-service class. Which situation is an example of malpractice? 1. The nurse fails to report a neighbor who is abusing his two children. 2. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122. 3. The nurse is suspected of taking narcotics prescribed for a client. 4. The nurse falsifies vital signs in the client's medical records. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

48. 1. The law states child abuse or suspected child abuse must be reported. The nurse is legally responsible to report child abuse or suspected child abuse. This is a legal issue, not malpractice. 2. Malpractice is a failure to meet the standards of care which results in harm to or death of a client. Failing to heed warnings of shock is an example of malpractice. 3. Stealing narcotics is a legal situation, not a malpractice issue. The nurse could have his or her nursing license revoked for this illegal behavior. 4. Falsifying documents is against the law. It is not a malpractice issue. TEST-TAKING HINT: The test taker must be knowledgeable of malpractice. Legal issues are dealt with by the laws of the state and federal government, and malpractice issues are dealt with in the state Nurse Practice Acts and in lawsuits in courts of law. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 2,3,4

49. The mother of a 20-year-old African American male client receiving dialysis asks the nurse, "My son has been on the transplant list longer than that white woman. Why did she get the kidney?" Which statement is the nurse's best response? 1. "The woman was famous, and so more people will donate organs now." 2. "I understand you are upset your son is ill. Would you like to talk?" 3. "No one knows who gets an organ. You just have to wait and pray." 4. "The tissues must match or the body will reject the kidney and it will be wasted." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

49. 1. There is a feeling during times of stress that organs may be distributed unfairly. Tissue and organ banks use the United Network of Organ Sharing (UNOS) to be as fair as possible in the allocation of organs and tissues. Organs will be given to the best match for the organ in the community where the donor dies. If no match is found in that area, then the search for an HLA match will be expanded to other areas of the country. The recipient is chosen based on HLA match, not fame or fortune. 2. The client is asking for information, which the nurse should provide. 3. There is a definite method of allocation of organs. 4. There are 27 known human leukocyte antigens (HLAs). HLAs have become the principal histocompatibility system used to match donors and recipients. The greater the number of matches, the less likely the client will reject the organ. Different races have different HLAs. TEST-TAKING HINT: Option "2" can be eliminated because the client asked for information. Option "1" can be eliminated because the statement supports an unethical situation. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 4

5. Which client would be most likely to complete an advance directive? 1. A 55-year-old Caucasian person who is a bank president. 2. A 34-year-old Asian licensed practical nurse. 3. A 22-year-old Hispanic lawn care worker. 4. A 65-year-old African American retired cook. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

5. 1. ADs are more frequently completed by white, middle- to upper-class individuals. 2. Many nurses do not have ADs, although they discuss them with clients daily. 3. Culturally, Hispanics allow their family members to make decisions for them. 4. Many cultures, including the African American culture, often distrust the health-care system and believe necessary care will be withheld if an AD is completed. TEST-TAKING HINT: If the test taker were not aware of the research, the test taker could examine the occupations and ask themselves, "Which client would want to direct his or her own care and make his or her own decisions?" Nurses may want this but many do not have ADs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 1

5. The hospice nurse is making the final visit to the wife whose husband died a little more than a year ago. The nurse realizes the husband's clothes are still in the closet and chest of drawers. Which action should the nurse implement first? 1. Discuss what the wife is going to do with the clothes. 2. Refer the wife to a grief recovery support group. 3. Do not take any action because this is normal grieving. 4. Remove the clothes from the house and dispose of them. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

5. 1. The nurse must first confront the wife about moving on through the grieving process. After one (1) year, the wife should be seriously thinking about what to do with her husband's belongings. 2. This is an appropriate intervention, but the nurse must first talk directly to the client. 3. After one (1) year, the wife should be progressing through the grieving process and needs encouragement to remove her husband's belongings. 4. This will need to be done at some point, but it is not the nurse's responsibility. This action is crossing professional boundaries unless the wife asks the nurse to do this. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 1

A nurse is reinforcing teaching with a newly hired assistive personnel about her role in helping older adult clients with activities of daily living. The nurse should explain that which of the following is the most common factor that affects a client's ability to perform ADLs? A. Social withdrawal B. Chronic physical disability C. Emotional impairment D. Cognitive dysfunction

B. Chronic physical disability

5. Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and two grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first? a. Ask the family members to leave the room if they are going to argue. b. Take the family members aside and explain that the patient may be able to hear them. c. Tell the family members that this decision is premature because the patient has not yet died. d. Remind the family that this should be the patient's decision and to ask her if she regains consciousness. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

5. b. Hearing is often the last sense to disappear with declining consciousness and conversations can distress patients even when they appear unresponsive. Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

50. The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family? 1. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile. 2. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death. 3. Tests will be done to determine if any brain activity exists before the machines are turned off. 4. Although the blood flow studies don't indicate activity, the client can still come out of the coma. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

50. 1. Positive brain waves on the EEG indicate brain activity, and the client is not brain dead. 2. This is called the oculovestibular test. If the client reacts, then it indicates brain activity and the client is not brain dead. 3. The Uniform Determination of Brain Death Act states brain death is determined by accepted medical standards which indicate irreversible loss of all brain function. Cerebral blood flow studies, EEG, and oculovestibular and oculocephalic tests may be done. 4. If the cerebral blood flow studies do not show acceptable blood flow to the brain, the client will not come out of the vegetative state. TEST-TAKING HINT: If the test taker examined all answer options and did not understand options "1," "2," and "4," then reading option "3" again would prove it to be the best choice because it simply states the machine won't be turned off until brain death has been proved. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 3

51. The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement? 1. Notify the organ and tissue organizations to make the retrieval. 2. Explain a systemic infection prevents the client from being a donor. 3. Call and notify the health-care provider of the family's request. 4. Take the body to the morgue until the organ bank makes a decision. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

51. 1. Many states require tissue and organ banks to be notified of all deaths, but the systemic infection eliminates this client from becoming a donor. 2. Septicemia is a systemic infection and will prevent the client from donating tissues or organs. 3. There is no reason to notify the HCP. 4. If the client were to be an organ donor, then the client's body would remain in the intensive care unit on the ventilator and with IV medication support until the organ bank team arrives and takes the client to the operating room. TEST-TAKING HINT: Option "3" could be eliminated from consideration because the nurse should be able to handle this situation. Option "4" could be eliminated because the client would have to stay on life support if the organ bank were to retrieve viable organs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 2

52. The client has received a kidney transplant. Which assessment would warrant immediate intervention by the nurse? 1. Fever and decreased urine output. 2. Decreased creatinine and BUN levels. 3. Decreased serum potassium and calcium. 4. Bradycardia and hypotension. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

52. 1. Oliguria, fever, increasing edema, hypertension, and weight gain are signs of organ rejection. 2. A decrease in serum creatinine and BUN would indicate the transplanted kidney is functioning well. 3. Potassium and calcium are not monitored for rejection. 4. The client with a fever might have tachycardia. Hypertension is a sign of rejection. TEST-TAKING HINT: Option "2" could be eliminated because of the word "decreased." If the test taker were aware of the role the kidneys play in controlling blood pressure, then option "4" could be eliminated. Decreased urine output in option "1" would make the most sense to choose because the kidneys produce urine. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 1

53. The client received a liver transplant and is preparing for discharge. Which discharge instruction should the nurse teach? 1. The immune-suppressant drugs must be tapered off when discontinuing them. 2. There may be slight foul-smelling drainage on the dressing for a few days. 3. Notify the HCP immediately if a cough or fever develops. 4. The skin will turn yellow from the antirejection drugs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

53. 1. The client must take an immune-suppressant medication forever unless a rejection occurs, and then the client would die without another transplant. 2. Foul-smelling drainage would indicate infection and is not expected. This would be an emergency situation. 3. Clients should be taught to notify the HCP immediately of any signs of an infection. The immune-suppressant drugs will mask the sign of an infection and superinfections can develop. 4. The skin turns yellow in liver failure; the antirejection drugs do not cause jaundice. TEST-TAKING HINT: Standard postoperative instructions include teaching the client to watch for any sign of an infection. Foulsmelling drainage is never normal. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

54. The pregnant client asks the nurse about banking the cord blood. Which information should the nurse teach the client? 1. The procedure involves a lot of pain with a very poor result. 2. The client must deliver at a large public hospital to do this. 3. The client will be charged a yearly storage fee on the cells. 4. The stem cells can be stored for about four (4) years before they ruin. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

54. 1. There is no pain associated with storing cord blood. The blood is taken from the separated placenta at birth. Forty to 150 mL of stem cells can be retrieved from the umbilical vein. 2. All hospitals which have an obstetrics department should be able to assist with the collection of stem cells. The client should notify the HCP to be prepared with the kit to obtain the specimens and to be able to send the stem cells to the Cord Blood Registry for processing and storage. 3. There is an initial fee to process the stem cells and a yearly fee to maintain the stored stem cells until needed. Stem cells may be used by the infant in case of a devastating illness or can be donated at the discretion of the owner. 4. This is true of stem cells which have been stored for more than 20 years. TEST-TAKING HINT: The test taker should recognize pain could not be associated with tissue which is no longer a part of the body. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

55. The nurse is caring for a client who received a kidney transplant from an unrelated cadaver donor. Which interventions should be included in the plan of care? Select all that apply. 1. Collect a urine culture every other day. 2. Prepare the client for dialysis three (3) times a week. 3. Monitor urine osmolality studies. 4. Monitor intake and output every shift. 5. Check abdominal dressing every four (4) hours. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

55. 1. Urine cultures are performed frequently because of the bacteriuria present in the early stages of transplantation. 2. A cadaver kidney may have undergone acute tubular necrosis and may not function for two (2) to three (3) weeks, during which time the client may experience anuria, oliguria, or polyuria and require dialysis. 3. Serum creatinine and BUN levels are monitored, but there is no need to monitor the urine osmolality. 4. Hourly outputs are monitored and compared with the intake of fluids. 5. The dressing is a flank dressing. TEST-TAKING HINT: The test taker should notice time frames. Anytime a specific time reference is provided, the test taker must determine if the time frame is the appropriate interval for performing the activity. In option "4," "every shift" is not appropriate. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 1,2

56. The client is three (3) hours post-heart transplantation. Which data would support a complication of this procedure? 1. The client has nausea after taking the oral antirejection medication. 2. The client has difficulty coming off the heartlung bypass machine. 3. The client has saturated three (3) ABD dressing pads in one (1) hour. 4. The client complains of pain at a "6" on a 1-to-10 scale. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

56. 1. The client would be NPO at this time and would be receiving parenteral antirejection medications. 2. The client would have been taken off the heart-lung bypass machine in the operating room. 3. Saturating three (3) dressing pads in one (1) hour would indicate hemorrhage. 4. Pain is expected and is not a complication of the procedure. TEST-TAKING HINT: The test taker should notice the time frame provided in the stem—in this case, three (3) hours after surgery. This could eliminate options "1" and "2." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

57. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a postoperative transplant unit. Which task should the nurse delegate to the UAP? 1. Assess the hourly outputs of the client who is post-kidney transplantation. 2. Raise the head of the bed for a client who is post-liver transplantation. 3. Monitor the serum blood studies of a client who has rejected an organ. 4. Irrigate the nasogastric tube of the client who had a pancreas transplant. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

57. 1. Assessment is always the nurse's responsibility and cannot be delegated. Hourly outputs are monitored to determine kidney function. 2. The UAP can perform this function. There is no nursing judgment required. 3. This requires nursing judgment and is outside the UAP's expertise. 4. Irrigating a nasogastric tube for a client who has undergone a pancreas transplant should be done by the nurse; this is a high-level nursing task. TEST-TAKING HINT: When asked to choose a task which can be delegated, the test taker should determine which task requires the least amount of judgment and choose that option. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 2

58. The experienced medical-surgical nurse is being oriented to the transplant unit. Which client should the charge nurse assign to this nurse? 1. The client who donated a kidney to a relative three (3) days ago and will be discharged in the morning. 2. The client who had a liver transplantation three (3) days ago and was transferred from the intensive care unit two (2) hours ago. 3. The client who received a corneal transplant four (4) hours ago and has developed a cough and is vomiting. 4. The client who had a pancreas transplantation and has a fever, chills, and a blood glucose monitor reading of 342. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

58. 1. This client is ready for discharge and is presumably stable. The client donated the kidney and still has one functioning kidney. An experienced medical-surgical nurse could care for this client. 2. This client must be observed closely for rejection of the organ and is newly transferred from the intensive care unit; therefore, a more experienced nurse in transplant care should care for this client. 3. This client has developed symptoms of a problem unrelated to the corneal transplant, but these symptoms will increase intracranial pressure, resulting in indirect pressure to the cornea. Therefore, a more experienced transplant nurse should care for this client. 4. This client is showing symptoms of organ rejection, which is a medical emergency and requires a more experienced transplant nurse. TEST-TAKING HINT: The test taker should choose the client with the fewest potential problems. The nurse is experienced as a medical-surgical nurse, but transplant recipients require more specialized knowledge. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 1

59. The 6-year-old client diagnosed with cystic fibrosis (CF) needs a lung transplant. Which individual would be the best donor for the client? 1. The 20-year-old brother who does not have cystic fibrosis. 2. The 45-year-old father who carries the cystic fibrosis gene. 3. The 18-year-old who died in an MVA who matches on four (4) points. 4. The 5-year-old drowning victim who is a three (3)-point match. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

59. 1. Living donors are able to donate some organs. The kidneys, a portion of the liver, and a lung may be donated, and the donor will still have functioning organs. An identical twin is the best possible match. However, in the situation in this question, the identical twin would also have CF because the genes would be identical. The next best chance for a compatible match comes from a sibling with both parents in common. 2. The father would have only half of the genetic makeup of the child. 3. There are at least 27 HLA types. A match requires at least 7, and preferably 10 to 11 points. 4. This is not an acceptable match; the client would reject the organ. TEST-TAKING HINT: If the test taker did not know the rationale, then a choice between options "1" and "2" would be the best option because of the direct familial relationships. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 1

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

6, 9, 2, 5, 7, 3, 1, 4, 8. This order provides dignity to the deceased and ensures that the nurse is adhering to all policies and laws concerning autopsies, organ donation, or an investigation.

6. The nurse is giving an in-service on end-of lifeissues. Which activity should the nurse encourage the participants to perform? 1. Discuss with another participant the death of a client. 2. Review the hospital postmortem care policy. 3. Justify not putting the client in a shroud after dying. 4. Write down their own beliefs about death and dying. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

6. 1. This activity will not help the nurse address his or her own fear of death. 2. This activity will not help the nurse address his or her own fear of death. 3. This activity will not help the nurse address his or her own fear of death. 4. Many nurses are reluctant to discuss death openly with their clients because of their own anxieties about death. Therefore, coming face to face with the nurse's own mortality will address the fear of death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 4

6. The client with an AD tells the nurse, "I have changed my mind about my AD. I really want everything possible done if I am near death since I have a grandchild." Which action should the nurse implement? 1. Notify the health information systems department to talk to the client. 2. Remove the AD from the client's chart and shred the document. 3. Inform the client he or she has the right to revoke the AD at any time. 4. Explain this document cannot be changed once it is signed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

6. 1. This department has nothing to do with the AD. 2. The most appropriate action would be for the nurse to have the client write on the AD he or she is revoking the document; the nurse cannot shred legal documents from the client's chart. 3. The client must be informed the AD can be rescinded or revoked at any time for any reason verbally, in writing, or by destroying his or her own AD. The nurse cannot destroy the client's AD, but the client can destroy his or her own. 4. This is an incorrect answer because the client always has the right to change his or her mind. TEST-TAKING HINT: Option "4" can be eliminated by remembering statements with absolutes should not be selected as correct answers unless the test taker knows for sure the answer is correct. The client's chart is a legal document, and these papers cannot be shredded or altered by using anything that obscures the writing or by erasing information. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 3

6. A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support? a. b. c. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

6. a. Coma b. Absent brainstem reflexes c. Apnea Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

60. Which tissue or organ can be repeatedly donated to clients needing a transplant? 1. Skin. 2. Bones. 3. Kidneys. 4. Bone marrow. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

60. 1. Skin is taken from cadaver donors, so it is given once. 2. Bones are taken from cadaver donors, so it is given once. 3. A kidney can be donated while the donor is living or both can be donated as cadaver organs, but either way the donation is only once. 4. The human body reproduces bone marrow daily. There is a bone marrow registry for participants willing to undergo the procedure to donate to clients when a match is found. TEST-TAKING HINT: The test taker could eliminate option "3" because the stem asks for repeated times and the client cannot live without kidney function. The client would have to be placed on dialysis or he or she would die. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 4

61. The nurse is admitting a client to the medicalsurgical unit. Which is required to be offered to the client if the hospital accepts Medicare reimbursement? 1. The opportunity to make an advance directive. 2. The client must be referred to a case manager. 3. The client must apply for a Medicare supplement insurance. 4. The opportunity to discuss end-of-life issues. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

61. 1. In the 1990s, Congress added the requirement for health-care facilities to offer clients the opportunity to receive an advance directive form and to be able to complete it to provide the health-care team with knowledge of the clients' wishes. It was added to a Medicare funding bill. 2. The client has to refuse or accept or alert the facility of an intact document about advanced decisions made by the client, but referral to a case manager is not attached to Medicare funding, 3. The client does not have to apply for supplemental insurance. 4. The opportunity may include end-of-life issues but it is not limited to end of life; it does include issues of irreversible situations and surrogate decision makers. TEST-TAKING HINT: The test taker could eliminate option "3" because the nurse cannot make the client do anything. The client has a right to say no. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 1

62. The nurse pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart? 1. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank. 2. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead. 3. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate. 4. Client found without pulse, body cold to touch. Pronounced deceased at 0900. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

62. 1. Clinical death is the absence of pulse, respirations, and blood pressure. It does not include radiology or other diagnostic tests. 2. If cardiopulmonary resuscitation is unsuccessful, the nurse cannot pronounce death. A physician must determine the reason for the death. 3. For it to be legal for a nurse to pronounce death, the client must have a disease process that could lead to death. The physician must write a clear order that the nurse can pronounce and be willing to document the cause of death on the death certificate. The observed clinical signs must be documented and the time pronounced. 4. This is an incomplete entry. TEST-TAKING HINT: The test taker could eliminate option "1" because clinical death is the absence of clinical signs of life. Option "3" is a complete documentation; the nurse states the facts without embellishment in documentation. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 3

63. The nurse is caring for an 82-year-old female client who is crying and asking for her mother to come to see her. Which statement represents the ethical principle of nonmalfeasance? 1. "You must miss your mother very much. Can you tell me about her?" 2. "You are 82 years old. Your mother is dead and can't come see you." 3. "Why do you need your mother? Can I get something for you?" 4. "Your mother would not want you to worry. I will tell her you want to see her." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

63. 1. The nurse is caring for a client who is at best disoriented; challenging this cognitive deficiency will only create frustration and anxiety in the client. Nonmalfeasance is the duty to prevent or do no harm. This is a therapeutic response that validates the client's concern but does not include lying to the client. 2. This is veracity, to tell the truth. 3. The client does not owe the nurse an explanation of why she wishes to see her mother. "Why" is not appropriate in this situation. 4. This is the opposite of veracity; it is lying to the client. If the nurse believes the client's mother to be dead, then how will the nurse contact her? TEST-TAKING HINT: The test taker could eliminate option "2" because it is veracity and "4" because it is lying. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 1

64. The hospice nurse is admitting a client. Which question concerning end-of-life care is most important for the nurse to discuss with the client and family? 1. Encourage the client and family to make funeral arrangements. 2. Assess the client's pain medication regimen for effectiveness. 3. Determine if the client has made an advance directive or living will. 4. Ask what durable medical equipment is in place in the home. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

64. 1. The nurse could possibly help the family to guide them about the need for eventual arrangements, but it is not appropriate during the admission process. 2. The client may or may not have pain; nothing indicates pain is an issue in the stem of the question. 3. Advance directives provide guidance for end-of-life care; the nurse needs this information in order to plan the care per the client's wishes. 4. This could be determined, but the priority is knowing the client's wishes. TEST-TAKING HINT: The test taker should recognize timing when reading a stem or option in a question. "On admission," "every day," "every two hours" will help to determine a correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 3

65. The client is dying and wants to talk to the nurse about heaven. Which is the nurse's best nursing action? 1. Make a referral to the chaplain to come to see the client. 2. Tell the client that nurses are not allowed to discuss spiritual matters. 3. Ask the client to describe heaven and hell. 4. Allow the client to discuss the beliefs about heaven. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

65. 1. Chaplains work with all faiths and are spiritual advisors. If the nurse feels comfortable with discussing heaven and if the client wishes to talk with the nurse, it is appropriate. 2. Nurses are not prohibited from discussing spiritual issues with a client; the nurse should not challenge the client's personal beliefs. 3. Hell is not what the client wants to talk about. 4. The nurse should allow the client to verbalize his/her feeling regarding what to expect when death occurs. TEST-TAKING HINT: The nurse student is taught in first-level courses to allow the client to verbalize feeling; the test taker should recognize this as basic nursing skills. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 4

66. The male client in the long-term care facility has been told that he will not live for many more months. The client has been estranged from his daughter for years. He tells the nurse that he could die a happy man if he could talk to his daughter just one more time. Which statement is the nurse's best response? 1. "You should not feel bad. Things will work out for the best before your death." 2. "What did you do to make your daughter not talk to you all this time?" 3. "If you would like I can try to contact your daughter and ask her to come see you." 4. "Tell me more about being unhappy that you don't have a relationship with your daughter." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

66. 1. This is false reassurance. 2. The blame for the lack of communication may not be the client's; it could be all on the daughter. This is an accusatory statement. 3. The nurse is asking permission to divulge the client's location and health status to the daughter; this is appropriate for complying with HIPAA and is addressing the voiced concerns of the client. 4. The nurse can perform an intervention that directly affects the client's situation. A therapeutic conversation might be used if the client's daughter is not willing to reconcile with the client. TEST-TAKING HINT: The test taker could eliminate option "1" because it is advising the client about how he should feel. Option "2" asks why and blames the client. Option "4" does not address the client's need. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 3

67. The nurse is caring for the family of the client who has just died. Which is the nurse's priority action? 1. Be with the family. 2. Call the funeral home. 3. Notify the minister. 4. Fill out the death certificate. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

67. 1. When a death occurs the need is for the nurse's presence; just being there with the family is what will help the family grieve. 2. The nurse may need to notify the funeral home, but the family is the priority need. 3. If the family wants the minister to be called, the nurse could do this, but, frequently, the family has a relationship with the minister and will need to speak directly with the minister to arrange the services. 4. The death certificate is completed by the physician signing it, not the nurse. TEST-TAKING HINT: The test taker could eliminate all options besides "1" because none of these will assist the grieving process. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 1

7. The client has just signed an AD at the bedside. Which intervention should the nurse implement first? 1. Notify the client's health-care provider about the AD. 2. Instruct the client to discuss the AD with significant others. 3. Place a copy of the advance directive in the client's chart. 4. Give the original advance directive to the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

7. 1. The HCP should be made aware of the AD, but this is not the first intervention. 2. This is the most important intervention because the legality of the document is sometimes not honored if the family members disagree and demand other action. If the client's family is aware of the client's wishes, then the health-care team can support and honor the client's final wishes. 3. Copies of the AD should be placed in the chart and given to significant others, the client's attorney, and all health-care providers. 4. The original should be given to the client and a copy should be placed in the chart, but this is not the first intervention. TEST-TAKING HINT: This is a priority-setting question, and the test taker should read all the answer options and try to rank them in order of priority. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 2

7. The 78-year-old Catholic client is in end-stage congestive heart failure and has a DNR order. The client has AP 50, RR 10, and BP 80/50, and Cheyne-Stokes respirations. Which action should the nurse implement? 1. Bring the crash cart to the bedside. 2. Apply oxygen via nasal cannula. 3. Notify a priest for last rites. 4. Turn the bed to face the sunset. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

7. 1. The client has a DNR; therefore, there is no need to bring the crash cart to the bedside. 2. The client has a DNR and the nurse needs to help the client die peacefully. 3. The Catholic religion requires last rites be performed immediately before or after death. 4. The client is Catholic, and there is no specific way for the bed to be placed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 3

7. A patient with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in 5 months, then I can die happy." The nurse recognizes that the patient is demonstrating which of the following stages of grieving? a. Prolonged grief disorder b. Kübler-Ross's stage of bargaining c. Kübler-Ross's stage of depression d. The new normal stage of the Grief Wheel Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

7. b. Bargaining is demonstrated by "if-then" grief behavior that is described by Kübler-Ross. Kübler-Ross's stage of depression is seen when the person says "yes me, and I am sad." Prolonged grief disorder is seen when there is a dysfunctional reaction to loss and the individual is unable to move forward after the death of a loved one. In the Grief Wheel model, the new normal stage is when the grief is resolved but the normal state, because of the loss, is not the same as before. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

A nurse is assisting with the admission of an older adult client who fell at home 3 days ago. The client has a fractured hip, malnutrition, and dehydration. Which of the following laboratory values, noted on admission, should indicate to the nurse prolonged malnutrition? A. Increased sodium B. Decreased albumin C. Increased BUN D. Decreased blood glucose

B. Decreased albumin

8. The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to "pull the plug." The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement? 1. Refer the case to the hospital ethics committee. 2. Tell the family they must do what the HCP orders. 3. Follow the HCP's order and "pull the plug." 4. Determine why the client did not complete an AD. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

8. 1. The ethics committee is composed of health-care workers and laypeople from the community to objectively review the situation and make a recommendation which is fair to both the client and health-care system. The family has the right to be present and discuss their feelings. 2. The nurse is legally obligated to be a client advocate. 3. This action could create a multitude of ramifications, including a lawsuit and possible criminal charges. 4. It really doesn't matter at this point why the client didn't complete an AD; the client cannot do it now. TEST-TAKING HINT: The test taker must be aware of the ethics committee and its role in helping resolve ethical dilemmas. Any answer option which has the word "why" should be evaluated closely before selecting it as the correct answer. Removing the endotracheal tube or turning off the ventilator ("pulling the plug") is a medical responsibility; therefore, option "3" could be eliminated as the correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 1

8. The Hispanic client who has terminal cancer is requesting a curandero to come to the bedside. Which intervention should the nurse implement? 1. Tell the client it is against policy to allow faith healers. 2. Assist with planning the visit from the curandero. 3. Refer the client to the pastoral care department. 4. Determine the reason the client needs the curandero. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

8. 1. The hospital should not prevent the client from practicing his or her culture, and denying faith healers would be denying the client's spiritual guidance. 2. The nurse should support the client's culture as long as it is not contraindicated in the client's care. This client is terminal; therefore, allowing the curandero, who is a folk healer and religious person in the Hispanic culture, would be appropriate. 3. There is no reason to refer this client to the pastoral care department; the nurse can assist the client. 4. The nurse does not need to know why the client wants the curandero; the nurse should support the client's request without prejudice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 2

8. A terminally ill man tells the nurse, "I have never believed there is a God or an afterlife, but now it is too terrible to imagine that I will not exist. Why was I here in the first place?" What does this comment help the nurse recognize about the patient's needs? a. He is experiencing spiritual distress. b. This man most likely will not have a peaceful death. c. He needs to be reassured that his feelings are normal. d. This patient should be referred to a clergyman for a discussion of his beliefs. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

8. a. Spiritual distress may surface when an individual is faced with a terminal illness and it is characterized by verbalization of inner conflicts about beliefs and questioning the meaning of one's own existence. Individuals in spiritual distress may be able to resolve the problem and die peacefully with effective grief work but referral to spiritual leaders should be the patient's choice. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

9. The client asks the nurse, "When will the durable power of attorney for health care take effect?" On which scientific rationale would the nurse base the response? 1. It goes into effect when the client needs someone to make financial decisions. 2. It will be effective when the client is under general anesthesia during surgery. 3. The client must say it is all right for it to become effective and enforced. 4. It becomes valid only when the clients cannot make their own decisions. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

9. 1. It is a power of attorney executed by a lawyer which allows a delegated other person to make financial decisions. That document has nothing to do with a durable power of attorney for health care. 2. The client has not lost the capacity to make decisions; therefore, a durable power of attorney cannot be used by the assigned person to make decisions. 3. The client must not be able to make his or her own decisions before this document can be used. 4. The client must have lost decision-making capacity as a result of a condition which is not reversible or must be in a condition which is specified under state law, such as a terminal, persistent vegetative state; an irreversible coma; or as specified in the AD. TEST-TAKING HINT: The test taker should not confuse a power of attorney and a durable power of attorney for health care. These are two separate, yet very important, documents with similar names. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 4

Nurses need to provide competent care to young and middle adult patients. Why must nurses be knowledgeable about developmental theories to care for this group? (Select all that apply.) a. These theories provide nurses with a basis for understanding the life events and developmental tasks of young and middle adults. b. It is important to understand societal structures and roles because they have not changed in the past 20 or 30 years. c. Patients present challenges to nurses, who themselves are often young or middle adults coping with the demands of their respective developmental period. d. Nurses need to recognize the needs of their patients even if they are not experiencing the same challenges and events.

A, C, D

9. Which interventions should the nurse implement at the time of a client's death? Select all that apply. 1. Allow gaps in the conversation at the client's bedside. 2. Avoid giving the family advice about how to grieve. 3. Tell the family the nurse understands their feelings. 4. Explain this is God's will to prevent further suffering. 5. Allow the family time with the body in private. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

9. 1. The nurse needs to be sensitive to the family, and simply being present to support the family emotionally is important; the nurse does not have to talk. 2. The nurse should avoid the impulse to give advice; each person grieves in his or her own way. 3. The nurse should not tell the family he or she understands; even if the test taker has lost a loved one, the test taker should never select an option which says the nurse understands another person's feelings. 4. This is projecting the nurse's personal religious beliefs on the family and could cause more anger at God when the family needs to be able to draw on their own spiritual beliefs. 5. The family needs time for closure, and allowing the family to stay at the bedside is meeting the family's need to say good-bye. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 1,2,5

9. In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents? a. Natural death acts c. Advance care planning b. Allow natural death d. Do Not Resuscitate order Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

9. a. Natural death acts in each state have their own requirements. Allow natural death is the new term being used for the Do Not Resuscitate order. Advance care planning is the process of having patients and their families think through their values and goals for treatment and document those wishes as advance directives. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility? a) Placing ID tags on the shroud and ankle b) Washing the body to remove blood and excretions c) Placing the body in normal anatomic position d) Removing tubes and soiled dressings

A

A nurse, working in paliative care, who experiences physical, emotional and spiritual exhaustion is suffering from what? A. Compassion fatigue B. Burnout C. Physcological drain D. Work stress overload

A

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which of the following would the nurse include in this education plan? a) Difficulty swallowing b) Increased urinary output c) Decreased pain d) Increased sensory stimulation

A

Describe Kubler-Ross' 5 stages of dying: A. Denial, Anger, Bargaining, Depression, Acceptance. B. Numbing, Yearning/Searching, Disorganization/Dispair, Reorganization. C. Accept reality, Experience pain, Adjust, Move on with life. D. Recognize loss, React/express pain, Reminisce, Relinquish attachments, Readjust.

A

Emotional response to a loss, which is unique to the individual. A. Grief B. Mourning C. Bereavement D. Normal Grief E. Complicated Grief

A

Form of necessary loss, including all normally expected life changes across the life span. A. Maturational losses B. Situational lossess C. Actual loss D. Perceived loss

A

It is important for a nurse to understand the grieving process because: A. It assists the nurse to understand the dynamics of grieving. B. It is important to understand the trajectory of grief. C. Understanding might influence how the nurse deals with death. D. It assists the nurse in guiding the bereaved through the stages of grieving in the optimal order.

A

Marginal or unsupported grief; the relationship may not be socially sanctioned. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

A

The goal of nursing interventions for a bereaved elderly person is to: A. Assist the bereaved individual to achieve a healthy adjustment to the loss. B. Encourage verbalization about the loved one. C. Guide the bereaved individual through the stages of grief in the usual order. D. Teach about the grieving process and offer support

A

The nurse working on a hospice unit is giving an in-service on the importance of faith and religion in client care. What does the nurse tell the group is a benefit of religious fellowship? a) It offers support for the client. b) It puts a good label on the client. c) It distracts the client. d) It allows for further isolation.

A

Which of the following is not an expected short-term outcome indicating effective grief inverventions? A. Decreased inner pain B. Talking about the loss without feeling overwhelmed C. Improved energy level D. Normalized sleep and dietary patterns E. Reorganization of life patterns F. Improved ability to make decisions G. Finding it easier to be around other people

A

Which statement about loss is accurate? A. Loss may be maturational, situational, or both. B. The degree of stress experienced is unrelated to the type of loss. C. Loss is only experienced when there is an actual absence of something valued. D. The more an individual has invested in what is lost, the less the feeling of loss.

A

A nurse is collecting data from an older adult client for signs of dehydration. Which of the following findings should the nurse consider an expected part of the aging process? A. Elevation of urine specific gravity B. Decreased creatinine clearance C. Dry oral mucous membranes D. Poor skin turgor over the sternum

B. Decreased creatinine clearance

A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiologic changes contribute to the development of type 2 diabetes? A. Increased production of insulin by the pancreas B. Decreased sensitivity to the circulating insulin C. Increased rate of glucose metabolism D. Decreased release of glycogen by the liver

B. Decreased sensitivity to the circulating insulin

The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient's family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse? a. "Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." b. "I will contact the provider to obtain an order to insert the tube and start tube feedings." c. "Intravenous fluids would be more comfortable for the patient than a tube feeding. I will call the doctor to get the order." d. "I will listen to the patient's abdomen to make sure that bowel sounds are present and try encouraging oral fluids."

ANS: A Common physical symptoms at the end of life include anorexia and cachexia. Tube feedings will cause discomfort as the tube is inserted and nausea as the GI tract is given food that it cannot handle. Encouraging oral intake will lead to increased secretions and congestion as well as possible aspiration of fluids. Intravenous fluids will increase congestion and edema. The nurse would educate the family on this part of the dying process.

The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body? a. Gently wash the body and provide perineal care. b. Remove the patient's dentures and jewelry. c. Ensure that the death certificate has been signed. d. Determine which funeral home will pick up the body

ANS: A Release of bowel and bladder contents often occur at the time of death, and the perineal care is a priority before the family arrives. The body should be gently cleaned to remove blood and debris from the accident. The patient's dentures and jewelry should not be removed from the body. The death certificate does not need to be signed before the family arrives. The family can decide which funeral home will be used and notify the nurse after their arrival.

The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle crash in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse? a. Check to make sure that the patient does not want to hurt or kill herself. b. Educate the patient about available support systems for grief resolution. c. Enhance the patient's coping skills to alleviate depression and anxiety. d. Encourage the patient to meet with a spiritual leader for guidance.

ANS: A The highest priority for the nurse is to ensure the safety of the patient, so assessment of potential suicidal tendencies is paramount. The other interventions can take place once the nurse is confident that the patient will not try to hurt or kill herself.

The nurse is caring for a patient who lost her husband 1 year ago after 55 years of marriage. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the Nursing diagnosis of complicated grieving applies to the patient. Which is the priority goal for the patient? a. The patient will shower every other day and eat at least two meals a day. b. The patient will identify personal strengths that will increase coping ability. c. The patient will discuss the meaning of her loss with a family member or friend. d. The patient will be provided with phone numbers for local community resources.

ANS: A The highest priority goal of this patient is self-care including showering and eating in order to protect her health and safety. The other goals are lower priority after the patient's necessary activities of daily living are addressed. Goals should also reflect what the patient accomplishes; so the goal of being provided with phone numbers is actually something for the nurse to do.

The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. The nurse identifies which term that best describes the activity of the patient's children? a. Anticipatory grieving b. Bereavement c. Caregiver role strain d. Death anxiety

ANS: A The patient and her children are experiencing anticipatory grief as they prepare for the expected death of the patient. Reminiscence and life review are used to assist those experiencing anticipatory grief with the realization that death is approaching.

The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, "Quit crying. It's not like you lost a real baby." What term best describes the anguish felt by the patient? a. Disenfranchised grief b. Delayed grief c. Moral distress d. Masked grief

ANS: A The patient is experiencing disenfranchised grief because she cannot share the pain of her loss with her husband. The husband is not willing to support his wife as she mourns the loss of her pregnancy or recognize the grief that she is going through. Delayed grief is suppression of the grief process. Moral distress occurs when people cannot act according to their moral values. Masked grief occurs when a person's bereavement behaviors interfere with his or her life, but the person does not notice this.

The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient's daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse? a. "Just let him know you are here, talk to him, and let him know that you love him." b. "You can try to feed him a few bites of ice cream to keep his mouth from getting dry." c. "You can take this time to ensure that arrangements are set with the funeral home." d. "You should let me know when your father's breathing pattern changes."

ANS: A The patient's daughter should be encouraged to spend the last moments of her father's life with him, reassuring him with her presence. The daughter should be encouraged to continue talking with him because the patient may still hear her even if his eyes are closed and he does not speak. The nurse is responsible for monitoring the patient for breathing changes. Oral intake will lead to nausea and/or aspiration. This is not the time to make arrangements with the funeral home.

The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention by the nurse will be most appropriate to meet this patient's wishes? a. Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. b. Assist the patient to reminisce and review his life, spending as much time as possible with loved ones. c. Use therapeutic touch, guided imagery, and soft music to put the patient at ease and relieve anxiety. d. Encourage the patient to participate in prayer and meditation along with preferred religious practices.

ANS: A The patient's primary wish is to die without pain, and the best intervention to meet this goal is administration of pain medication around the clock with extra doses for breakthrough pain. The other interventions may make the patient more comfortable but will not address his primary desire for adequate pain management.

The nurse is caring for a patient who has just died. Which assessment findings by the physician and nurse are used to confirm that death has occurred? (Select all that apply.) a. The patient was incontinent of bowel and bladder. b. The patient's pupils are fixed and dilated. c. The provider does not hear a heartbeat. d. The patient's extremities are cool and mottled. e. The patient has no palpable peripheral pulses. f. The patient's face is relaxed and the mouth is open.

ANS: A, B, C, E Assessment findings that confirm death has occurred include lack of pulse/heartbeat and fixed dilated pupils. Cool, mottled extremities, relaxed muscles, and incontinence of bowel and/or stool are common assessment findings in patients who are dying.

The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated by the nurse to the nursing assistant? (Select all that apply.) a. Gently washing the body and closing the patient's eyes b. Offering support and empathy to the patient's family members c. Documenting the patient's time of death in the medical record d. Notifying all of the patient's consulting providers of the patient's death e. Removing the patient's hospital ID band, IV lines, and urinary catheter f. Gathering the patient's belongings so they may be taken home by the family

ANS: A, B, F The nurse assistant can gently wash the patient's body, close the patient's eyes, and gather the patient's belongings. Offering support and empathy to the patient's family members would be done by all of the involved members of the nursing staff. Documenting the time of death in the chart and notifying all of the patient's providers is performed by the nurse. The nurse assistant can remove the patient's IV lines and urinary catheter if allowed by policy, but the hospital ID band would be left in place.

The nurse is caring for an Islamic patient who has just died. The family is traveling from overseas. Which action is the priority for the nurse to take right after the patient dies? a. Arranging for embalming to preserve the body until burial b. Rearrange the furniture so the bed can face Mecca c. Arranging for transportation of the body to the crematorium d. Bringing in fruit for the patient's journey to the other world

ANS: B After death, a patient's body can be turned to face Mecca which is the holy site for Muslims. The nurse would need to find out which direction that is. The family will work with the funeral home to determine when and where burial will take place. Buddhists often bring fruit when someone dies.

The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse? a. "The insurance company will not pay for chemotherapy at this stage." b. "The focus right now needs to be on keeping your loved one comfortable." c. "I will call the provider and relay your wishes." d. "The patient needs to get stronger first before chemotherapy can be administered."

ANS: B Nurses advocate for patients to ensure that they are aware of their options for care that include interventions, treatments, anticipated outcomes, as well as risk and benefits of any decision made concerning medical care. The nurse must function as the patient's advocate and encourage what is in the best interest of the patient. Chemotherapy will not extend the patient's life when death is expected within the next few days and will only make the patient suffer needlessly when it is administered. The patient will not get stronger over the next few days, and this criterion for chemotherapy will never be met.

The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse? a. Reorient the patient and reassure that nobody else is in the room. b. Be present but quiet and let the patient continue the conversation. c. Carefully assess the patient's mental status and level of attention. d. Obtain a set of vital signs and check the patient's pulse oximetry.

ANS: B Patients who are near death sometimes have a special communication with loved ones who have already died. It is important to recognize that these experiences can be comforting to the dying patient, and nurses would not contradict or argue with the person. It is imperative to simply be present with the person, listen, and be open to any attempts to communicate. It is acceptable to ask gentle questions such as "What are you seeing?" or "How does that make you feel?" Having an open discussion with the family while describing what is occurring may provide further insight to the nurse as the health care provider, as well as promoting a sense of understanding and acceptance for the family. As long as the patient is calm and content, the best action of the nurse is to be present but let the patient continue the conversation undisturbed.

The nurse sees a young child in the clinic whose mother has only a few weeks to live. The child has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. The nurse identifies which stage of grieving that the patient is experiencing? a. Denial b. Anger c. Bargaining d. Depression

ANS: B The patient is angry over the impending death of the mother and is acting out this anger at school by picking fights and defying his teachers. Denial is a temporary defense while processing the information. Bargaining is negotiation to change the predicted outcome. Depression includes crying and sadness.

The hospice nurse is caring for a terminally ill patient. The patient's son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient's son currently? a. Chronic grief related to impending death of mother b. Death anxiety related to feeling powerless over situation c. Powerlessness related to progression of mother's terminal illness d. Complicated grieving related to desired avoidance of mourning

ANS: B The patient's son is experiencing death anxiety because he is unable to change the outcome of his mother's imminent death. The son makes no mention of religious beliefs, so impaired religiosity is not appropriate. Complicated grieving is applicable to individuals who have recently experienced a loss. Chronic grief is grief that continues for a long period of time.

The hospice nurse is caring for a several adult children shortly after the death of a parent. They have various reactions as they deal with their loss. The nurse recognizes which reactions to be in the cognitive domain? a. They let the house get filthy because they can't be bothered to clean it. b. They are tossing and turning all night and are unable to get a good night's sleep. c. They are easily distracted and often lose train of thought during conversation. d. They have lost their appetites and have no desire to eat anything.

ANS: C Cognitive deficits include the inability to concentrate and follow a conversation. Letting the house get filthy is a sign of apathy, which is in the behavioral domain. Insomnia falls within the behavioral and physical domains. Loss of appetite is within the physical domain.

The hospice nurse is caring for a patient who is terminally ill. The patient's spouse is the primary caregiver, providing constant care and spending all his or her time meeting the patient's needs. The spouse says to the nurse "After my spouse dies, I will finally get that colonoscopy my provider has been bugging me about." What does the nurse understand about this statement? a. The spouse is looking forward to being freed from the caretaker role. b. The spouse has neglected his or her own physical needs for too long. c. The spouse is making some realistic plans for life after the death. d. The spouse is in denial that the patient is dying and the important role of caregiver will end.

ANS: C Often caregivers neglect their own needs while in the caregiver role. The spouse understands the patient will die soon and is being realistic in understanding his or her own physical needs have been neglected. This shows healthy coping.

The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention? a. Encouraging the patient to limit fluid intake to minimize congestion b. Limiting the use of pain medications so that the patient can visit with family c. Helping the patient to identify and complete desired tasks and activities d. Completing funeral arrangements with the patient's next of kin

ANS: C The priority intervention for the nurse currently is to help the patient identify and complete desired tasks and activities while the patient is still able to do so. Pain management is a high priority at this time, so analgesics should never be limited unless requested by the patient. The patient can drink as much or as little fluid as desired.

A nurse is collecting data from an older adult client during an annual physical. Which of the following findings should the nurse report to the provider? A. BP 118/76 mm Hg B. Fasting blood glucose level 160 mg/dL C. Report of waking to void two to three times per night D. Report of a bowel movement every other day

B. Fasting blood glucose level 160 mg/dL

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's sweet-16 birthday party, I'll be ready to die." The nurse notes that the client is experiencing which phase of coping?

Bargaining

The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse currently? a. Inform the patient's family that the body must be transported to the morgue. b. Instruct the patient's family that hospital staff will provide postmortem care. c. Obtain needed signatures for organ donation and autopsy. d. Offer to provide any needed supplies and provide privacy for the family.

ANS: D The most appropriate action of the nurse currently is to allow the family to wash the patient's body in accordance with their wishes and cultural values. The family may wish to participate in this procedure or may complete this procedure in private. Health care personnel should abide by their wishes as much as possible. Signatures may be obtained from the next of kin when washing is complete. The patient's body may be transported to the morgue or funeral home after washing is completed.

The nurse is caring for a patient who died a few minutes ago. The patient's family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient's body. What is the most appropriate action of the nurse? a. Inform the family that the patient's body must be taken to the morgue shortly. b. Ask the family members to step outside while postmortem care is provided. c. Obtain required signatures for the body to be taken to the funeral home. d. Provide privacy and allow the patient's family to grieve over the body.

ANS: D The nurse should allow the patient's family to grieve in private over the loss of their loved one. Some cultures favor free expression of emotions after death, and the nurse should respect this. Signatures can be obtained, postmortem care can be provided, and the body brought to the morgue after an appropriate time of grieving has been provided to the family.

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation?

Administering intravenous (IV) fluids

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life?

Anxiety

A client who has been diagnosed with a terminal illness has an advance directive form, needs it to be signed, and asks the nurse to sign it as a witness. What is the nurse's best action?

Ask a nonmedical client, such as a social worker, to witness the form.

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?

Ask the client who might be available to serve as a witness.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse?

Assess the client's and the spouse's perception of the event.

A 61-year-old obese patient is diagnosed with type 2 diabetes and high blood pressure. The patient states that he is upset about the diet restrictions imposed by the treatment regimen. What is the nurse's best approach? a. Tell the patient that he must do what the doctor tells him. b. Offer counseling on nutrition and exercise. c. Tell the patient about what happened to other patients who did not change their lifestyle. d. Explain that he needs to accept the care provider's advice without question if he wants to get better.

B

A nurse who works effectively with elderly clients who are dying and their families recognizes that: A. Hospice services are preferable as death nears. B. The nurse must be comfortable with her own concerns and feelings about death. C. Most people are not afraid to die if they have adequate information about what is happening. D. At least some pain accompanies most deaths

B

Question 15 Type: MCSA A terminally ill patient and the family agree that the physician will write a do-not-resuscitate order for the patient. The nurse understands that what should be implemented when following this order? 1. Do not call a code if the patient stops breathing or the heart stops beating. 2. Call a code only if the patient stops breathing. 3. Call a code only if the patient's heart stops beating. 4. Withhold food and fluids but provide pain medication

Correct Answer: 1 Rationale 1: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. Rationale 2: This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. Rationale 3: When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. Rationale 4: Withholding food and fluids but providing pain medication would be elements of a comfort-measures-only order. Global Rationale: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. Withholding food and fluids but providing pain medication would be elements of a comfort-measures-only order.

Question 37 Type: MCSA A patient tells the nurse, "I dread going on after the divorce is final. I have no idea how I am going to manage financially or emotionally." The nurse realizes this patient is demonstrating which aspect of Caplan's stress and loss theory? 1. living without the assets and guidance 2. psychic pain 3. reduced problem-solving ability 4. emotional turmoil

Correct Answer: 1 Rationale 1: According to Caplan's theory of stress and loss, there are three factors that influence a person's ability to deal with a loss. This patient is demonstrating the factor of "living without the assets and guidance of the lost person or resource." Rationale 2: Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. Rationale 3: The patient is not demonstrating an inability to handle her problems according to the data provided. Rationale 4: Emotional turmoil is not a specific factor cited in Caplan's theory. Global Rationale: According to Caplan's theory of stress and loss, there are three factors that influence a person's ability to deal with a loss. This patient is demonstrating the factor of "living without the assets and guidance of the lost person or resource." Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. The patient is not demonstrating an inability to handle her problems according to the data provided. Emotional turmoil is not a specific factor cited in Caplan's theory.

Question 3 Type: MCSA A patient tells the nurse that since his wife died he has not been able to sleep and sees no reason to continue living. According to Freud's theory on grief and loss, what should the nurse realize this patient is experiencing? 1. depression 2. grieving 3. emancipation 4. denial

Correct Answer: 1 Rationale 1: According to Freud's theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Rationale 2: Grieving is the inner labor of mourning a loss. The patient is not grieving. Rationale 3: Emancipation is not an element of Freud's theory of grief and loss. Rationale 4: Denial is not element of Freud's theory of grief and loss. Global Rationale: According to Freud's theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Grieving is the inner labor of mourning a loss. The patient is not grieving. Emancipation and denial are not elements of Freud's theory of grief and loss.

Question 9 Type: MCSA After an unsuccessful resuscitation attempt, a patient dies. What should the nurse do first? 1. Document the time of death. 2. Notify the funeral home. 3. Contact the physician. 4. Contact the orderly for transport to the morgue

Correct Answer: 1 Rationale 1: After death, the time must be recorded in the patient's record. Rationale 2: Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family's wishes. Rationale 3: After documentation is completed, the attending physician will require notification. Rationale 4: The body can be transported to the morgue after family members have been notified and allowed to see their loved one. Global Rationale: After death, the time must be recorded in the patient's record. After documentation is completed, the attending physician will require notification. Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family's wishes. The body can be transported to the morgue after family members have been notified and allowed to see their loved one.

Question 5 Type: MCSA A 30-year-old terminally ill patient is concerned about how her 7-year-old child will perceive her death. What advice from the nurse would be most beneficial? 1. Children this age recognize that death is permanent. 2. Children this age emotionally distance themselves from the death. 3. Because the child fears separation the patient can prepare the child by explaining that death is permanent. 4. Children this age think death is sleeping

Correct Answer: 1 Rationale 1: Age is a great determinant of beliefs about death. Children this age understand the finality of death. Rationale 2: At the age of 7, children do not have the emotional maturity to distance themselves from death. Rationale 3: The ability to understand separation has been mastered by the age of 7. Rationale 4: Children this age do not think that death is sleeping. Global Rationale: Age is a great determinant of beliefs about death. Children this age understand the finality of death. At the age of 7, children do not have the emotional maturity to distance themselves from death. The ability to understand separation has been mastered by the age of 7. Children this age do not think that death is sleeping

A nurse is reinforcing teaching with a group of older adult female clients who are postmenopausal about dietary requirements. Which of the following statements about the role of folic acid should the nurse take? A. "Clients who are postmenopausal need to limit their intake of folic acid to reduce their risk of stroke." B. "Dietary folic acid is not of significant importance after the childbearing years." C. "Healthy clients who are postmenopausal require a daily folic acid supplement." D. "Adequate folic acid intake is associated with a reduced risk for heart disease."

D. "Adequate folic acid intake is associated with a reduced risk for heart disease."

Question 7 Type: MCSA A patient tells the nurse that her estranged husband died a little over a year ago and states, "I am not sure why this is so difficult. I really couldn't stand him near the end." Which response by the nurse is most appropriate? 1. "Sometimes a rocky relationship with someone at the time of their death can affect your ability to grieve." 2. "You seem angry." 3. "You should contact a therapist." 4. "You are just entering the grief process. Things will get better."

Correct Answer: 1 Rationale 1: An ambivalent relationship prior to the loss can affect a person's ability to grieve. Rationale 2: The patient does not seem angry. Rationale 3: It is inappropriate for the nurse to refer the patient to a therapist. Rationale 4: As the death occurred over a year ago, the patient is experiencing impaired grieving. Global Rationale: An ambivalent relationship prior to the loss can affect a person's ability to grieve. The patient does not seem angry. It is inappropriate for the nurse to refer the patient to a therapist. As the death occurred over a year ago, the patient is experiencing impaired grieving

The brother of a terminally ill patient states, "I'll donate a million dollars to the hospital if they cure my brother." The nurse realizes this statement indicates which phase of Kübler-Ross's stages of loss? 1. bargaining 2. denial 3. anger 4. acceptance

Correct Answer: 1 Rationale 1: Bargaining is an attempt to postpone or in some way affect the reality of the loss. Rationale 2: The brother is not expressing denial. Rationale 3: The brother does not appear to be angry. Rationale 4: The brother is not expressing acceptance. Global Rationale: Bargaining is an attempt to postpone or in some way affect the reality of the loss. The brother is not expressing denial or acceptance and does not appear to be angry.

Question 8 Type: MCSA A terminally ill patient is demonstrating signs of spiritual distress. Which should the nurse do first to assist this patient? 1. Use the FICA assessment. 2. Help the patient with guided imagery. 3. Offer to pray with the patient. 4. Leave the patient alone with her thoughts

Correct Answer: 1 Rationale 1: Because the nurse often feels uncertain about implementing interventions that would be helpful to the patient responding to a loss, the FICA assessment can be used to assess a patient's spiritual or religious practices. Rationale 2: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Rationale 3: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Rationale 4: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Global Rationale: Because the nurse often feels uncertain about implementing interventions that would be helpful to the patient responding to a loss, the FICA assessment can be used to assess a patient's spiritual or religious practices. The nurse should use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts.

Question 12 Type: MCSA A terminally ill patient nearing end of life is dehydrated and complains of being thirsty. What can the nurse do to make the patient more comfortable? 1. Provide oral care every 2 hours. 2. Increase intravenous fluids. 3. Raise the head of the bed. 4. Begin enteral feedings.

Correct Answer: 1 Rationale 1: Dehydration in the patient nearing death causes discomfort primarily from dry mouth and thirst. The patient should be given oral care at least every 2 hours, and more often if the patient is breathing through the mouth. Rationale 2: Increasing intravenous fluids could cause peripheral and lung edema. Rationale 3: Raising the head of the bed helps with dyspnea, not dehydration. Rationale 4: Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst. Global Rationale: Dehydration in the patient nearing death causes discomfort primarily from dry mouth and thirst. The patient should be given oral care at least every 2 hours, and more often if the patient is breathing through the mouth. Increasing intravenous fluids could cause peripheral and lung edema. Raising the head of the bed helps with dyspnea, not dehydration. Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst.

Question 4 Type: MCSA A patient has decided to join a support group for surviving spouses of victims of violent crime. According to Engel's theory of grief and loss, the nurse identifies that this patient is in which stage? 1. restitution 2. acute grief 3. shock and disbelief 4. denial

Correct Answer: 1 Rationale 1: During restitution the mourner continues to feel a painful void, is preoccupied with thoughts of the loss, and may join a support group or seek other social support for coping with the loss. Rationale 2: Acute grief is initiated by shock and disbelief. Rationale 3: Acute grief is initiated by shock and disbelief. Rationale 4: Acute grief is initiated by shock and disbelief, which may manifest as denial. Global Rationale: During restitution the mourner continues to feel a painful void, is preoccupied with thoughts of the loss, and may join a support group or seek other social support for coping with the loss. The patient who is joining a support group is in the stage of restitution. Acute grief is initiated by shock and disbelief, which may manifest as denial.

Question 38 Type: MCSA A patient who is a recent widow states, "I wanted to ask him for a divorce and then he died." What should the nurse realize this patient is at risk for developing? 1. an accelerated grief reaction 2. a dysfunctional grief reaction 3. a typical grief reaction process 4. psychosomatic disorders

Correct Answer: 1 Rationale 1: Factors that can interfere with a successful grieving reaction include ambivalent relationships prior to the loss. Rationale 2: This statement does not necessarily indicate that a dysfunctional grief reaction. Rationale 3: The patient's intentions may prevent a typical grief reaction. Rationale 4: This statement does not necessarily indicate that the patient may develop a psychosomatic disorder. Global Rationale: Factors that can interfere with a successful grieving reaction include ambivalent relationships prior to the loss. This statement does not necessarily indicate a dysfunctional grief reaction or the likelihood of a psychosomatic disorder. The patient's intentions may prevent a typical grief reaction.

A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (AP). Which of the following statements by the AP indicates understanding of this review? A. "I'm sure the family is hopeful that the new medication will stop the illness." B. "I'll miss working with this client, now that only nurses will be caring for him." C. "I will get all the client's personal objects out of his room." D. "I will listen and respond as the family talks about heir child's life."

D. "I will listen and respond as the family talks about heir child's life."

Question 44 Type: MCSA A dying patient tells the nurse, "Don't let my family leave me." What should the nurse realize this patient is demonstrating? 1. fear of dying alone 2. the anticipation of improving in health 3. the need for the family to see the patient improve 4. the desire to prolong life

Correct Answer: 1 Rationale 1: Family members are often afraid to be present at the time of death, yet dying alone is the greatest fear expressed by patients. Rationale 2: There is no information provided to indicate there will be a recovery or improvement in the patient's condition. Rationale 3: There is no information provided to indicate there will be a recovery or improvement in the patient's condition. Rationale 4: While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone. Global Rationale: Family members are often afraid to be present at the time of death, yet dying alone is the greatest fear expressed by patients. There is no information provided to indicate there will be a recovery or improvement in the patient's condition. While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone.

Question 17 Type: MCSA While preparing for the discharge of a terminally ill older adult patient, the family asks for information concerning the most appropriate time to become involved with a hospice agency. Which action by the nurse is most correct? 1. Assist the family with making contact with a hospice agency at this time. 2. Determine the patient's life expectancy to gauge when the contact should be made. 3. Encourage the family to "hold off" making the contact until death is very close. 4. Determine what expectations the family has of the hospice agency.

Correct Answer: 1 Rationale 1: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. Rationale 2: It is inappropriate to try to determine life expectancy. This is an inaccurate measurement of the degree of services needed. Rationale 3: Waiting until the time of death nears does not leave much time for the hospice agency to assist the family. Rationale 4: Determining the family's expectations concerning hospice is an inappropriate action for the nurse. Global Rationale: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. It is inappropriate to try to determine life expectancy. This is an inaccurate measurement of the degree of services needed. Waiting until the time of death nears does not leave much time for the hospice agency to assist the family. Determining the family's expectations concerning hospice is an inappropriate action for the nurse.

Question 19 Type: MCSA A patient asks the nurse what it means to have hospice care at home. What should the nurse respond to this patient? 1. "Hospice makes sure that you are comfortable at home." 2. "Hospice care helps cure your illness." 3. "Hospice care is for patients who will be sick for longer than a year." 4. "Hospice care means your physical needs will be met."

Correct Answer: 1 Rationale 1: Hospice care focuses on comfort care versus curative care. Rationale 2: The focus of hospice is on care, not cure. It is care for patients with limited life expectancy. Rationale 3: Patients receiving hospice care are generally defined as those who have a prognosis of 6 months or less if their terminal disease runs a normal course. Rationale 4: The care plan includes both the patient and family/caregiver as the unit of care, and the care plan is written to meet their values and goals. Global Rationale: Hospice care focuses on comfort care versus curative care. It is care for patients with limited life expectancy. The care plan includes both the patient and family/caregiver as the unit of care, and the care plan is written to meet their values and goals. Patients receiving hospice care are generally defined as those who have a prognosis of 6 months or less if their terminal disease runs a normal course.

Question 34 Type: MCSA A patient who had a below-the-knee amputation 2 months ago is seen walking with a new limb prosthesis and returning to work. What does the nurse realize about this patient? 1. The patient has completed the work of mourning the loss of the leg. 2. The patient is having difficulty with grief. 3. The patient is in denial. 4. The patient is forgetting about the disease that caused the loss of the limb.

Correct Answer: 1 Rationale 1: In one theory of the process of loss, the person gradually withdraws attachment to the lost object or person. The period of mourning, or work of mourning, ends and the person reaches a state of completion. This is the time when the patient may be ready to move on and make a change such as using a prosthesis or return to activities they were involved in before the loss. Rationale 2: The patient's actions indicate a positive adaptation, not an inability to manage grief. Rationale 3: Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. Rationale 4: There is inadequate information provided to infer the patient has forgotten about the disease which caused the loss of the limb. Further, forgetting an event of this magnitude is extremely unlikely. Global Rationale: In one theory of the process of loss, the person gradually withdraws attachment to the lost object or person. The period of mourning, or work of mourning, ends and the person reaches a state of completion. This is the time when the patient may be ready to move on and make a change such as using a prosthesis or return to activities they were involved in before the loss. The patient's actions indicate a positive adaptation, not an inability to manage grief. Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. There is inadequate information provided to infer the patient has forgotten about the disease which caused the loss of the limb. Further, forgetting an event of this magnitude is extremely unlikely.

Question 20 Type: MCSA A patient with a chronic illness asks the nurse if the new medication is going to cure the disease. Which is the nurse's best response? 1. "It will help you be more comfortable. I don't think it's going to cure the disease." 2. "Of course it's going to cure the disease." 3. "If you believe it will cure the disease, then it will." 4. "I don't think it's going to help or hurt at this time."

Correct Answer: 1 Rationale 1: In palliative care, the nurse needs to be honest with the patient and explain that the medication will help with comfort, but will not cure the chronic illness. Rationale 2: In palliative care, the nurse needs to be honest with the patient and explain that the medication will not cure the disease. Rationale 3: The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. Rationale 4: The nurse has no way of knowing whether the medication will help or hurt the patient. Global Rationale: In palliative care, the nurse needs to be honest with the patient and explain that the medication will help with comfort, but will not cure the chronic illness. The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. The nurse has no way of knowing whether the medication will help or hurt the patient.

An older adult client tells a nurse at a health fair "I am always forgetting things. I cannot even remember where I parked my car! Do you think I have Alzheimer's disease?" Which of the following is a therapeutic response by the nurse? A. "Maybe. Perhaps you should discuss your concerns with your doctor." B. "I am forgetful too. I can't remember where I parked my car either!" C. "You're probably just having 'senior movements.' Everyone has memory lapses." D. "That must be very upsetting. Can you tell me about your forgetfulness?"

D. "That must be very upsetting. Can you tell me about your forgetfulness?"

Question 2 Type: MCSA A patient tells the nurse that her husband passed away a year ago and she is now beginning to realize that he is truly gone. The patient is planning to begin a new job and possibly move to a new community. The nurse realizes that this patient is in which stage of Bowlby's theory of attachment? 1. detachment 2. protest 3. despair 4. anger

Correct Answer: 1 Rationale 1: In the stage of detachment the person realizes the permanence of the loss and expresses readiness to move forward. This is what the patient is doing when planning to begin a new job and move to a new community. Rationale 2: The protest phase is marked by a lack of acceptance of the loss. Rationale 3: In despair, the person's behavior becomes disorganized. Rationale 4: Anger is not a stage within Bowlby's theory of attachment. Global Rationale: In the stage of detachment the person realizes the permanence of the loss and expresses readiness to move forward. This is what the patient is doing when planning to begin a new job and move to a new community. The protest phase is marked by a lack of acceptance of the loss. In despair, the person's behavior becomes disorganized. Anger is not a stage in Bowlby's theory of attachment

Question 11 Type: MCSA A terminally ill patient is experiencing dyspnea and tells the nurse that he feels like he is suffocating. What can the nurse do to assist this patient? 1. Keep the room cool with a slight breeze. 2. Increase the heat in the room. 3. Provide additional intravenous fluids. 4. Assist the patient to a sitting position out of bed.

Correct Answer: 1 Rationale 1: Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. Rationale 2: Raising the temperature in the room will not reduce the feeling of suffocation. Rationale 3: Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation. Rationale 4: The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed. Global Rationale: Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. Raising the temperature in the room will not reduce the feeling of suffocation. Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation. The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed.

Question 14 Type: MCSA At the time of admission, a patient with a terminal illness tells the nurse that her daughter will be allowed to make health-related decisions if she becomes incapacitated. What should the nurse realize this patient is specifically describing? 1. healthcare surrogate 2. living will 3. durable power of attorney 4. advance directive

Correct Answer: 1 Rationale 1: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. Rationale 2: The living will provides written directions about life-prolonging decisions. Rationale 3: The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual's behalf. Rationale 4: Advance directives are legal documents that allow a person to plan for healthcare and/or financial affairs in the event of incapacity. They include living wills, health care surrogates, and durable power of attorney. Global Rationale: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. The living will provides written directions about life-prolonging decisions. The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual's behalf. Advance directives are legal documents that allow a person to plan for healthcare and/or financial affairs in the event of incapacity. They include living wills, healthcare surrogates, and durable power of attorney.

Question 10 Type: MCSA A terminally ill patient is experiencing secretions pooling in the back of the throat. What can the nurse do to help this patient feel more comfortable? 1. Raise the head of the bed. 2. Gently massage the patient. 3. Provide frequent small sips of fluids. 4. Provide oral care.

Correct Answer: 1 Rationale 1: The nurse should reposition the patient and raise the head of the bed if fluids accumulate in the upper airways and back of the throat. Rationale 2: Gentle massage helps with accumulating edema of the extremities. Rationale 3: Small sips of fluids help with the discomfort of drying oral mucous membranes. Rationale 4: Oral care helps with the discomfort of drying oral mucous membranes. Global Rationale: The nurse should reposition the patient and raise the head of the bed if fluids accumulate in the upper airways and back of the throat. Gentle massage helps with accumulating edema of the extremities. Small sips of fluids and oral care help with the discomfort of drying oral mucous membranes.

Question 13 Type: MCSA A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided. The family members are not supportive of this directive. Which action by the nurse is the most appropriate? 1. Place the document on the chart. 2. Contact the Social Services department. 3. Notify the hospital attorney. 4. Explain to the patient that the conflict could invalidate the document.

Correct Answer: 1 Rationale 1: The patient is competent, and the wishes of the patient must take priority. The document should first be placed on the chart and the physician notified. Rationale 2: If there are concerns about the authenticity of the document, the Social Services department will need to be contacted. Rationale 3: If there are concerns about the authenticity of the document, the unit supervisor or hospital attorney will need to be contacted. Rationale 4: A lack of support by the family does not invalidate the document. Global Rationale: The patient is competent, and the wishes of the patient must take priority. The document should first be placed on the chart and the physician notified. If there are concerns about the authenticity of the document, the Social Services department, hospital attorney, or unit supervisor will need to be contacted. A lack of support by the family does not invalidate the document.

Question 46 Type: MCSA A patient who has recently loss his spouse states, "I just can't cry." What should the nurse realize this patient is at risk for developing? 1. psychological issues 2. depression 3. overemotionality 4. somatic symptoms

Correct Answer: 4 Rationale 1: There is no indication this patient will face an increased risk for the development of psychological issues. Rationale 2: There is no indication this patient will face an increased risk for the development of depression. Rationale 3: Crying is considered a typical and expected part of the grief reaction in most grief theories. Rationale 4: The inability to express grief can lead to the onset of somatic, or physical, symptoms. Global Rationale: The inability to express grief can lead to the onset of somatic, or physical, symptoms. Crying is considered a typical and expected part of the grief reaction in most grief theories. There is no indication this patient will face an increased risk for the development of psychological issues or depression.

Question 18 Type: MCSA A terminally ill patient is receiving palliative care. What does the nurse understand the purpose of this type of care to be? 1. alleviating suffering and enhancing quality of life 2. reducing pain and preventing medical complications 3. controlling side effects of illness while postponing death 4. withdrawing all medical care to allow natural death

Correct Answer: 1 Rationale 1: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Rationale 2: Medical complications can be controlled but not prevented. Rationale 3: The purpose is not specifically to postpone death. Rationale 4: Withdrawing all medical care would be inappropriate as it would cause more suffering. Global Rationale: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Medical complications can be controlled but not prevented. The purpose is not specifically to postpone death. Withdrawing all medical care would be inappropriate as it would cause more suffering.

Question 6 Type: MCSA A patient of Native American descent is expected to die. The family arrives at the hospital and wants to observe their religious and cultural traditions. Which intervention by the nursing staff would be most appropriate? 1. Offer the family a private room to sit together. 2. Discourage the family from sitting with their loved one prior to death. 3. Discuss the possibility of transferring the patient home for the death. 4. Encourage the family to consider a DNR order.

Correct Answer: 1 Rationale 1: Traditional Native Americans prefer to mourn in private, away from the dying patient. Rationale 2: It is not appropriate for the nurse to discourage the family from spending time with the patient at this critical point. Rationale 3: The severity of the patient's condition does not allow for transfer at this time. Rationale 4: Some tribes prefer not to openly discuss DNR decisions. Global Rationale: Traditional Native Americans prefer to mourn in private, away from the dying patient. It is not appropriate for the nurse to discourage the family from spending time with the patient at this critical point. The severity of the patient's condition does not allow for transfer at this time. Some tribes prefer not to openly discuss DNR decisions.

Question 16 Type: MCSA A terminally ill patient who does not have an advance directive or do-not-resuscitate order in place stops breathing. What should the nurse do to assist this patient? 1. Call a code. 2. Initiate a slow code. 3. Contact the physician to assess the patient for death. 4. Contact the nursing supervisor.

Correct Answer: 1 Rationale 1: Without an advance directive or do-not-resuscitate order, the nurse is legally responsible for calling a code on the terminally ill patient who has stopped breathing. Rationale 2: To initiate a slow code would be malpractice. Rationale 3: The nurse needs to call a code, not call the physician. Rationale 4: The nurse needs to call a code, not call the nursing supervisor. Global Rationale: Without an advance directive or do-not-resuscitate order, the nurse is legally responsible to call a code on the terminally ill patient who has stopped breathing. To initiate a slow code would be malpractice. The nurse needs to call a code, not call the physician or the nursing supervisor.

Question 22 Type: MCMA The nurse is caring for a patient who is nearing death from a terminal illness. The patient is experiencing secretions in the back of the throat and dyspnea. Which medications should the nurse provide to assist this patient? Standard Text: Select all that apply. 1. Oxygen 2. Morphine 3. Atropine 4. Scopolamine 5. Demerol

Correct Answer: 1, 2, 3, 4 Rationale 1: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with oxygen. Rationale 2: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with opioids. Rationale 3: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with medications that reduce secretions, such as atropine. Rationale 4: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with medications that reduce secretions, such as scopolamine. Rationale 5: Meperidine (Demerol) is not useful for chronic pain because it has a short half-life and a toxic metabolite that can cause irritability and seizures. Global Rationale: As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with oxygen, opioids, and medications that reduce secretions, such as atropine and scopolamine. Meperidine (Demerol) is not useful for chronic pain because it has a short half-life and a toxic metabolite that can cause irritability and seizures.

Question 48 Type: MCMA A patient with a terminal illness says that when the pain becomes too unbearable he plans to take an overdose of pain medication and end it all. How should the nurse respond to this patient's plan? Standard Text: Select all that apply. 1. "Do you have a living will?" 2. "Have you assigned durable power of attorney to anyone?" 3. "Have you considered a healthcare surrogate?" 4. "Have you researched methods for self-euthanasia?" 5. "Have you talked with your healthcare provider about orders for life-sustaining treatment?"

Correct Answer: 1, 2, 3, 5 Rationale 1: A living will is a document that provides written directions about life-prolonging procedures to follow when an individual can no longer communicate in a life-threatening situation. Rationale 2: Durable power of attorney is a document that can delegate the authority to make healthcare decisions. Rationale 3: A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. Rationale 4: Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient. Rationale 5: A physician order for life-sustaining treatment (POLST) is a form for patients with serious, progressive, chronic illnesses that translates their wishes regarding life-sustaining treatment into actionable medical orders. Global Rationale: A living will is a document that provides written directions about life-prolonging procedures to follow when an individual can no longer communicate in a life-threatening situation. Durable power of attorney is a document that can delegate the authority to make healthcare decisions. A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. A physician order for life-sustaining treatment (POLST) is a form for patients with serious, progressive, chronic illnesses that translates their wishes regarding life-sustaining treatment into actionable medical orders. Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient.

Question 49 Type: MCMA A patient who nearing the end of life is irritable and uncomfortable in bed. Which actions should the nurse take to make the patient more comfortable? Standard Text: Select all that apply. 1. Raise the head of the bed. 2. Apply bed pads over the linens. 3. Gently massage the extremities. 4. Reduce the amount of pain medication. 5. Use a draw sheet to turn the patient.

Correct Answer: 1, 2, 3, 5 Rationale 1: Actions to help this patient achieve comfort include raising the head of the bed. Rationale 2: Actions to help this patient achieve comfort include applying bed pads over the linens. Rationale 3: Actions to help this patient achieve comfort include gently massaging the extremities. Rationale 4: Reducing the amount of pain medication can increase this patient's level of pain. Rationale 5: Actions to help this patient achieve comfort include using a draw sheet when turning. Global Rationale: Actions to help this patient achieve comfort include raising the head of the bed, applying bed pads over the linens, gently massaging the extremities, and using a draw sheet when turning. Reducing the amount of pain medication can increase this patient's level of pain.

A nurse discusses the risks of repeated sun exposure with a young adult patient. Which of these patient responses would be most expected from this patient? a. "I'll make an appointment with my doctor right away for a full skin check." b. "I should consider participating in a health fair about safe sun practices." c. "I have a mole that has been bothering me. I'll call my family doctor for an appointment to get it checked." d. "I've had this mole my whole life. So what if it changed color? My skin is fine."

D.

Question 52 Type: MCMA During a home visit the nurse determines that a patient whose spouse died 10 months ago is demonstrating signs of grief resolution. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Not living in the past 2. Breaking ties with the lost person 3. Asking for help to end the pain of the loss 4. Experiencing waves of sadness when looking at a picture 5. Wishing that death had occurred at the same time the spouse died

Correct Answer: 1, 2, 4 Rationale 1: Evidence that grief is resolving includes not living in the past. Rationale 2: Evidence that grief is resolving includes breaking ties with the lost person. Rationale 3: Asking for help to end the pain of the loss indicates that grief resolution is not occurring. Rationale 4: Evidence that grief is resolving includes experiencing waves of sadness when looking at a picture. Rationale 5: Wishing for death at the same time that the spouse died indicates that grief resolution is not occurring. Global Rationale: Evidence that grief is resolving includes not living in the past, breaking ties with the lost person, and experiencing waves of sadness when looking at a picture. Asking for help to end the pain of the loss and wishing for death at the same time that the spouse died indicates that grief resolution is not occurring.

Question 51 Type: MCMA A patient whose spouse passed away 5 years ago becomes severely depressed on holidays, anniversaries, and birthdays. What should the nurse do to help this patient? Standard Text: Select all that apply. 1. Encourage the patient to talk with family or spiritual support systems. 2. Explain that these feelings are a sign of chronic depression. 3. Help the patient talk about the loss and hopes for the future. 4. Explain that these feelings will last as long as the patient is alive. 5. Role-play ways for the patient to get through the days when depression is the worst.

Correct Answer: 1, 3, 4, 5 Rationale 1: For the patient with chronic sorrow the nurse should encourage the patient to talk with family or others in the patient's spiritual support system. Rationale 2: These feelings are not a sign of chronic depression. Rationale 3: For the patient with chronic sorrow the nurse should encourage the patient to talk about the loss and hopes for the future. Rationale 4: For the patient with chronic sorrow the nurse should explain that these feelings will last as long as the patient is alive. Rationale 5: For the patient with chronic sorrow the nurse should role-play ways for the patient to get through the days when the depression is the worst. Global Rationale: For the patient with chronic sorrow the nurse should encourage the patient to talk with family or others in the patient's spiritual support system, help the patient talk about the loss and hopes for the future, explain that these feelings will last as long as the patient is alive, and role-play ways for the patient to get through the days when the depression is the worst. These feelings are not a sign of chronic depression.

Question 29 Type: FIB A patient diagnosed with pancreatic cancer is prescribed strict intake and output. During the last shift, the patient received 1 liter of 0.9% normal saline; two 50-milliliter doses of morphine sulfate in 0.9% normal saline; 3 ounces water. What should the nurse calculate this patient's total intake for the previous shift to be?

Correct Answer: 1,190 Rationale: To calculate the patient's total intake, 1 liter of 0.9% normal saline is 1,000 mL. Add this to 100 mL for the two doses of morphine sulfate to equal 1,100 mL. The oral intake of 3 ounces is converted to 90 mL (1 ounce = 30 mL). The patient's total intake for the previous shift was 1,190 mL.

Question 23 Type: MCMA The sibling of a patient who is nearing death has insisted on intravenous fluids because "My brother wants to live." Which findings should the nurse expect when assessing this patient? Standard Text: Select all that apply. 1. The nurse notes the presence of inspiratory and expiratory crackles in all lung fields. 2. The nurse notes that there is increasing edema in the patient's ankles and feet bilaterally. 3. The patient has developed ascites. 4. The patient has lost 6 pounds from last week. 5. The nurse learns during shift report that the patient vomited three times during the night shift.

Correct Answer: 1,2,3,5 Rationale 1: Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs. Rationale 2: Initiating intravenous fluids for hydration purposes in the dying patient may lead to peripheral edema. Rationale 3: Initiating intravenous fluids for hydration purposes in the dying patient may lead to ascites. Rationale 4: The patient is much less likely to lose weight at this time. Rationale 5: Initiating intravenous fluids for hydration purposes in the dying patient may lead to vomiting. Global Rationale: Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs, peripheral edema, ascites, and vomiting. The patient is much less likely to lose weight at this time.

Question 31 Type: MCMA A patient diagnosed with terminal cancer tells the nurse that she knows everything about a living will. Upon assessment, the nurse realizes the patient needs additional instruction on this type of advance directive when the patient makes which statements? Standard Text: Select all that apply. 1. "A living will is a document in which I designate someone to make healthcare-related decisions for me in the event I become unconscious." 2. "A living will is a document in which I designate someone to make healthcare and legal decisions for me in the event I become unconscious." 3. "A living will is a document in which I designate my personal wishes and which directions to follow in the event I become unconscious." 4. "A living will is a document in which I designate which directions to follow in the event I become unconscious, but the directions can be modified by my family." 5. "A living will is a document in which my family designates someone to make decisions for me in the event I become unconscious."

Correct Answer: 1,2,4,5 Rationale 1: A healthcare surrogate is an individual that the patient designates to make healthcare decisions for the patient in the event the patient is unable to do so. Rationale 2: Durable power of attorney is a document that delegates the authority to make legal, healthcare, and financial decisions for the patient in the event the patient is unable to do so because of a change in health status. Rationale 3: A living will is a document in which the patient designates those wishes and directions to follow in the event of terminal illness or permanent unconsciousness. Rationale 4: A living will cannot be modified by the patient's family. A living will is not created for another person; therefore, the family cannot make a living will for a patient. Rationale 5: A living will is not created by the patient's family. Global Rationale: A living will is a document in which the patient designates those wishes and directions to follow in the event of terminal illness or permanent unconsciousness. A healthcare surrogate is an individual that the patient designates to make healthcare decisions for the patient in the event the patient is unable to do so. Durable power of attorney is a document that delegates the authority to make legal, healthcare, and financial decisions for the patient in the event the patient is unable to do so because of a change in health status. A living will is not created by the patient's family and cannot be modified by the family. A living will is not created for another person; therefore, the family cannot make a living will for a patient.

A nursing student is asked to compare major life events of young adult, middle adult, and childbearing families. Which statement by the student demonstrates understanding? a. "Young adults have gained sexual experience and do not need sexual education." b. "Once a woman has her baby, stress levels decrease, as does health risk." c. "The social pressure to get married is greater now than it ever was." d. "When married people both work, income is increased, but so is stress."

D.

Bereavement may be defined as: A The emotional response to loss B The outward, social expression of loss C Postponing the awareness of the reality of the loss. D The inner feeling and outward reactions of the survivor

D.

Question 24 Type: MCMA A patient of Mexican American descent is dying. Which statements by the patient's only son are expected? Standard Text: Select all that apply. 1. "We have already notified our priest about Dad's condition." 2. "When the time of death gets closer, we would like him transferred to the inpatient hospice unit at the hospital." 3. "My sister is pregnant, so she really can't help with his care." 4. "My family members will be here at the house a lot right now." 5. "We don't want to worry him, so if there is any change in his condition, please talk to me about it."

Correct Answer: 1,3,4,5 Rationale 1: It is important that the patient's priest be notified. Rationale 2: It would be unusual for the family of this patient to express the wish to transfer the patient from home to a hospital. Mexican American families often prefer that the patient die at home. Rationale 3: Pregnant women do not care for dying persons or attend funerals. Rationale 4: Extended family members are obligated to pay respects to the sick and dying. Rationale 5: Based on the belief that worry may make health worse, the family may want to protect the patient from the seriousness of illness. The information is often handled by an older daughter or son. Global Rationale: It is important that the patient's priest be notified. Pregnant women do not care for dying persons or attend funerals. Extended family members are obligated to pay respects to the sick and dying. Based on the belief that worry may make health worse, the family may want to protect the patient from the seriousness of illness. The information is often handled by an older daughter or son. It would be unusual for the family of this patient to express the wish to transfer the patient from home to a hospital. Mexican American families often prefer that the patient die at home.

Question 30 Type: MCMA The nurse suspects a patient is in the final stages of the dying process. What manifestations did the nurse assess in this patient? Standard Text: Select all that apply. 1. change in level of consciousness 2. sudden increase in taste and smell 3. urinary incontinence 4. increased blood pressure 5. irregular heart rate

Correct Answer: 1,3,5 Rationale 1: Assessment findings consistent with the late stages of the dying process include a change in level of consciousness. Rationale 2: There is a decrease, not an increase, in taste and smell. Rationale 3: Assessment findings consistent with the late stages of the dying process include incontinence of bowel and bladder. Rationale 4: Blood pressure will decrease. Rationale 5: Assessment findings consistent with the late stages of the dying process include an irregular heart rate. Global Rationale: Assessment findings consistent with the late stages of the dying process include a change in level of consciousness, incontinence of bowel and bladder, and an irregular heart rate. There is a decrease, not an increase, in taste and smell. Blood pressure will decrease.

Question 40 Type: MCSA The nurse is assessing a dying patient's spiritual beliefs about death. Which acronym represents topics the nurse can use to help with this assessment process? 1. ABC 2. FICA 3. DABDA 4. RACE

Correct Answer: 2 Rationale 1: ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient's spiritual beliefs about death. Rationale 2: Faith, influence, community, and address form the acronym FICA. These topics can help the nurse move through the spiritual assessment process with a patient. Rationale 3: DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross's stages of grieving. Rationale 4: RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation. Global Rationale: Faith, influence, community, and address form the acronym FICA. These topics can help the nurse move through the spiritual assessment process with a patient. ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient's spiritual beliefs about death. DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross's stages of grieving. RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation.

Question 42 Type: MCSA The family of a dying patient wants to help relieve the patient's progressive dyspnea. What should the nurse instruct the family to do for the patient? 1. Lower the head of the bed. 2. Raise the head of the bed. 3. Suction the patient as much as possible. 4. Perform chest physiotherapy.

Correct Answer: 2 Rationale 1: Nursing care to improve respirations does not include lowering the head of the bed. Rationale 2: Nursing care to improve respirations includes raising the head of the bed. Rationale 3: Suctioning would be considered an advanced care measure and is not indicated in the scenario. Rationale 4: Chest physiotherapy would be considered an advanced care measure and is not indicated in the scenario. Global Rationale: Nursing care to improve respirations includes raising, not lowering, the head of the bed. Suctioning and chest physiotherapy would be considered advanced care measures and are not indicated in the scenario.

Question 36 Type: MCSA The spouse of a former patient tells the nurse that he has joined a support group to help with the loss of his wife. The nurse realizes this patient is in which phase of Engel's grief process? 1. acute 2. restitution 3. long-term 4. resolution

Correct Answer: 2 Rationale 1: The acute phase is initiated by shock and disbelief, manifested by denial. Rationale 2: According to Engel, there are three phases of the grief process: acute, restitution, and long-term. It is during restitution that the surviving spouse might join a support group to help cope with the loss. Rationale 3: During the long-term phase, the individual begins to come to terms with the loss and renew activities. Rationale 4: Resolution is associated with the acceptance of the loss but is not one of the phases in Engel's grief process. Global Rationale: According to Engel, there are three phases of the grief process: acute, restitution, and long-term. It is during restitution that the surviving spouse might join a support group to help cope with the loss. The acute phase is initiated by shock and disbelief, manifested by denial. During the long-term phase, the individual begins to come to terms with the loss and renew activities. Resolution is associated with the acceptance of the loss but is not one of the phases in Engel's grief process.

During middle adulthood, the 50-year-old patient is likely to adapt favorably to a changing body image if he or she a. Decreases the amount of physical exercise. b. Eats a diet composed of 40% fat. c. Gets less than 5 hours of sleep per night. d. Engages in good hygiene practices.

D.

What are the stages of dying according to Elizabeth Kubler-Ross? A Numbing; yearning and searching; disorganization and despair; and reorganization. B Accepting the reality of loss, working through the pain of grief, adjusting to the environment without the deceased, and emotionally relocating the deceased and moving on with life. C Anticipatory grief, perceived loss, actual loss, and renewal. D Denial, anger, bargaining, depression, and acceptance

D.

Question 41 Type: MCSA The patient states, "My husband is the person you should talk with if I am not able to make decisions about my care." What should the nurse realize the spouse has been designated to be? 1. the person who has the patient's living will 2. the healthcare surrogate 3. the person with the durable power of attorney 4. nothing more than the spouse

Correct Answer: 2 Rationale 1: The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for health care. Rationale 2: A healthcare surrogate is the person selected by the patient to make medical decisions when the patient is no longer able to make them for him- or herself. Rationale 3: Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney. Rationale 4: A healthcare surrogate is the person selected to make medical decisions when a person is no longer able to make them for him- or herself. The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for health care. Global Rationale: A healthcare surrogate is the person selected by the patient to make medical decisions when the patient is no longer able to make them for him- or herself. The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for health care. Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney

Question 50 Type: MCMA A patient with a terminal illness is experiencing severe nausea and vomiting. Which medications should the nurse consider appropriate for the patient at this time? Standard Text: Select all that apply. 1. Furosemide (Lasix) 2. Ondansetron (Zofran) 3. Meperidine (Demerol) 4. Morphine sulfate (Morphine) 5. Prochlorperazine (Compazine

Correct Answer: 2, 5 Rationale 1: Furosemide (Lasix) is a diuretic. Rationale 2: Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. Rationale 3: Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. Rationale 4: Morphine sulfate (Morphine) is an analgesic, which could be causing this patient's nausea and vomiting. Rationale 5: Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. Global Rationale: Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. Furosemide (Lasix) is a diuretic. Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. Morphine sulfate (Morphine) is an analgesic, which could be causing this patient's nausea and vomiting.

Question 35 Type: MCMA A patient who has just lost her spouse asks the nurse how long it will be until she feels like living again. The nurse realizes this patient has to work through which phases of the grieving process according to Bowlby? Standard Text: Select all that apply. 1. denial 2. despair 3. detachment 4. protest 5. restitution

Correct Answer: 2,3,4 Rationale 1: Denial is associated with feelings of disbelief. Rationale 2: The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate she has acknowledged the event. Rationale 3: The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate she has acknowledged the event. Rationale 4: The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate she has acknowledged the event. Rationale 5: Restitution is a stage in Engel's theory of loss. Global Rationale: The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate she has acknowledged the event. Denial is associated with feelings of disbelief. Restitution is a stage in Engel's theory of loss.

Question 32 Type: MCMA The nurse is instructing others on the use of hospice care. Which statements would indicate to the nurse that the teaching session has been effective? Standard Text: Select all that apply. 1. "Hospice care is designed for individuals with a terminal prognosis who cannot stay at the hospital." 2. "Hospice care is designed for individuals with a terminal prognosis who decide to spend their final days at home with their families." 3. "Hospice care is designed for individuals with a terminal prognosis who decide to stay in the hospital for symptom management." 4. "Hospice care is designed for individuals with a terminal prognosis who have to go into a hospice center for proper symptom management." 5. "Hospice care is designed for individuals with a terminal prognosis who decide to receive treatment for their symptoms at home, the hospital, or the hospice center."

Correct Answer: 2,3,5 Rationale 1: Hospice care can be received in the home, hospital, hospice center, or community. Rationale 2: Hospice care is a philosophy of care designed for the individual with a terminal prognosis and the individual's family members. Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient. Rationale 3: Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient. Rationale 4: Hospice care can be received in the home, hospital, hospice center, or community. Rationale 5: Hospice care can be received either at home, the hospital, hospice center, or the community. Global Rationale: Hospice care is a philosophy of care designed for the individual with a terminal prognosis and the individual's family members. Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient

When performing a thorough psychosocial assessment on a young adult, what must the nurse realize? a. Having a job is the best way to relieve stress. b. Although psychologically disturbing, stress does not lead to physical illness. c. Change is inevitable and is not a factor in stress-related illness. d. Psychosocial health is often related to job and family stress.

D.

A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes for the older adult include: A. a transition from young adulthood. B. the ability of the older adult to achieve sexual arousal. C. a time when cognitive performance begins to peak. D. adjusting to decreasing health and physical strength.

D. adjusting to decreasing health and physical strength

The unconscious process of disengaging before the actual loss or death occurs. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

F

Question 33 Type: MCMA A young adult male patient diagnosed with terminal pancreatic cancer tells the nurse that if he lets his hair grow, God will cure him. What should the nurse realize this patient is demonstrating? Standard Text: Select all that apply. 1. The patient is having delusions and is using religious beliefs to block his loss. 2. The patient is bargaining and is postponing his loss. 3. The patient is in denial, and his religious beliefs block his loss. 4. The patient is normal; bargaining with God for physical healing reflects a stage of grieving. 5. The patient is feeling anger and is using his religious beliefs to project his loss.

Correct Answer: 2,4 Rationale 1: The patient is not delusional and is not using religious beliefs to block the loss. Rationale 2: Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. Rationale 3: The patient is also not in denial and using his religious beliefs to block the loss. Rationale 4: Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. Rationale 5: Bargaining with God is not a demonstration of anger. Global Rationale: Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. The patient is not delusional or in denial and is not using religious beliefs to block the loss. Bargaining with God is not a demonstration of anger.

Question 43 Type: MCSA The family of a dying patient states, "She has to be in pain, because all she does is moan." What should the nurse realize this family is doing? 1. overreacting 2. asking for more pain medication for the patient 3. not understanding that moaning can be agitation in the patient 4. considering moaning to be a sign the patient is recovering

Correct Answer: 3 Rationale 1: The responses by the family are typical and do not reflect excessive concern. Rationale 2: There is no indication that the family is requesting pain medication. Rationale 3: Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. Rationale 4: The family thinks she is in pain, which would not indicate an improvement in status. Global Rationale: Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. The family thinks she is in pain, which would not indicate an improvement in status. The responses by the family are typical and do not reflect excessive concern. There in no indication that the family is requesting pain medication.

Question 47 Type: MCSA A preoperative patient says to the nurse, "I hope I wake up after surgery. I don't know what my family would do if I didn't." The nurse realizes this patient is demonstrating which potential problem? 1. coping 2. chronic sorrow 3. anticipatory grieving 4. death anxiety

Correct Answer: 3 Rationale 1: This patient is expressing a feeling, not demonstrating coping. Rationale 2: This patient is not demonstrating chronic sorrow, which is a "cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced in response to continual loss, throughout the trajectory of an illness or disability." Rationale 3: Anticipatory grieving is a combination of intellectual and emotional responses and behavior by which people adjust their self-concept in the face of a potential loss. Rationale 4: This patient is not experiencing death anxiety, which is worry or fear related to death or dying. It may be present in patients who have an acute life-threatening illness, who have a terminal illness, who have experienced the death of a family member or friend, or who have experienced multiple deaths in the same family. Global Rationale: Anticipatory grieving is a combination of intellectual and emotional responses and behavior by which people adjust their self-concept in the face of a potential loss. This patient is expressing a feeling, not demonstrating coping. This patient is not demonstrating chronic sorrow, which is a "cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced in response to continual loss, throughout the trajectory of an illness or disability." This patient is not experiencing death anxiety, which is worry or fear related to death or dying. It may be present in patients who have an acute life-threatening illness, who have a terminal illness, who have experienced the death of a family member or friend, or who have experienced multiple deaths in the same family.

Question 39 Type: MCSA A patient tells the nurse, "My husband left me to be with God." What should the nurse realize this patient is demonstrating? 1. coping 2. denial 3. a regional difference in the way death is expressed 4. a cultural rite related to death

Correct Answer: 3 Rationale 1: This patient statement does not indicate coping. Rationale 2: This patient statement does not indicate denial. Rationale 3: Regional differences in the way death is expressed in the United States include "passed away," "went to be with God," and "passed from this life." Rationale 4: This patient statement does not reflect a cultural rite. Global Rationale: Regional differences in the way death is expressed in the United States include "passed away," "went to be with God," and "passed from this life." This statement does not reflect coping, denial, or a cultural rite.

Question 21 Type: SEQ A patient is explaining her experiences after the sudden death of her daughter a few years ago. If Elizabeth Kübler-Ross's sequence is applied, in which order did the patient experience the stages of death and dying? Rank the patient's statements in the order they would have been made. Standard Text: Click and drag the options below to move them up or down. Choice 1. "I have to admit I tried to make a deal with God to bring her back to me." Choice 2. "I'm going to try to use my experience with her illness to help other parents." Choice 3. "I cannot get my mind around it. I still keep waiting for her to come home from school." Choice 4. "I can hardly get out of bed because I just want to sleep." Choice 5. "I just feel so mad at her for leaving me!"

Correct Answer: 3,5,1,4,2 Rationale 1: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Bargaining is the third stage. Rationale 2: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Acceptance is the final stage. Rationale 3: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Denial is the first stage. Rationale 4: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Depression is the fourth stage. Rationale 5: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Anger is the second stage. Global Rationale: Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. The stages are denial, anger, bargaining, depression, and finally acceptance.

Question 45 Type: MCSA The nurse who provided care to a terminally ill patient does not want to spend any time with the grieving family and begins to provide care to another patient. What is this nurse demonstrating? 1. empathy 2. apathy 3. overemotionality 4. blunting

Correct Answer: 4 Rationale 1: Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. Rationale 2: Apathy is an emotion characterized by a lack of concern and involvement. Rationale 3: Overemotionality is not a recognized term. Rationale 4: Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle his or her emotions appropriately right after the death, and this is a coping mechanism. Global Rationale: Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle his or her emotions appropriately right after the death, and this is a coping mechanism. Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. Apathy is an emotion characterized by a lack of concern and involvement. Overemotionality is not a recognized term.

Question 27 Type: SEQ A patient diagnosed with testicular cancer tells the nurse that he does not believe he has cancer. The nurse realizes that the patient may be progressing through the stages of grief. Place in order the stages of grief. Standard Text: Click and drag the options below to move them up or down. Choice 1. depression Choice 2. acceptance Choice 3. anger Choice 4. denial Choice 5. bargaining

Correct Answer: 4,3,5,1,2 Rationale 1: The fourth stage, depression, occurs when the patient realizes the full impact of the loss. Rationale 2: The final stage is acceptance and occurs when the patient accepts the conditions of the illness and begins to plan or hope for the future. A patient may or may not experience all of the stages in this process. Rationale 3: The second stage is anger, when the patient demonstrates anger over the situation. Rationale 4: The patient is currently in the stage of denial by refusing to accept the diagnosis. Kübler-Ross's stages of grieving begin with denial. Rationale 5: The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. Global Rationale: The patient is currently in the stage of denial by refusing to accept the diagnosis. Kübler-Ross's stages of grieving begin with denial. The second stage is anger, when the patient demonstrates anger over the situation. The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. The fourth stage, depression, occurs when the patient realizes the full impact of the loss. The final stage is acceptance and occurs when the patient accepts the conditions of the illness and begins to plan or hope for the future. A patient may or may not experience all of the stages in this process.

Question 28 Type: FIB A patient being treated for terminal cancer is prescribed morphine sulfate through a continuous intravenous infusion. The pharmacy is requesting the patient's current weight in kilograms. During the last measurement, the patient's weight was documented as 128 lbs. What should the nurse calculate this patient's weight in kg to be?

Correct Answer: 58.1 Rationale: To calculate the patient's weight in kilograms, the nurse should divide the weight in pounds by 2.2. This calculation would be 128/2.2 = 58.1 kg.

A client who is on hospice care and has no immediate family has been given less than 1 week to live. The nurse caring for the client recognizes that providing presence is most important, especially when a client is dying. What would be the best way for this nurse to provide presence to this client? a) Check on this client every hour. b) Tell the client that you are there when needed and to just ring the call bell. c) Sit in the chair on the other side of the room for 10 minutes each hour. d) Hold the client's hand and sit by the bedside as often as possible.

D

A hospice nurse is providing emotional care and support for a family who lost a son. The care will be provided based on what knowledge? a) Grief is an abnormal physical reaction to a loss. b) Bereavement is a normal process, requiring little intervention. c) All members of the family will react to loss in the same way. d) Stages of grief reactions may overlap and are individualized.

D

A nurse is uncomfortable discussing spiritual concerns with a dying client. The most helpful action for the client would be for the nurse to plan to: A. Make an attempt to meet the client's needs in this area, even if uncomfortable. B. Ask to be removed from the care of that client. C. Seek personal counseling to improve skills in this area. D. Request a member of the pastoral care staff visit the client

D

A patient often actively engages in reminiscence when the nurse is delivering care. The nurse recognizes that: a) reminiscence should be discouraged until the patient is discharged. b) reminiscence occurs when a patient withdraws from usual roles. c) reminiscence interferes with the patient's ability to accept death. d) reminiscence is a normal process in achieving ego integrity.

D

A priority nursing intervention for an elderly person who is dying and experiencing anxiety is to: A. Contact family members to alert them and enlist their help. B. Allow the client time alone to conduct a life review. C. Explain that anxiety is a common experience. D. Assist the individual to identify fears.

D

Are uniquely defined by the person experiencing loss and are less obvious to other people. A. Maturational losses B. Situational lossess C. Actual loss D. Perceived loss

D

As a nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you will want to: A. Complete a course on death and dying B. Control your emotions about death and dying C. Compare this experience to the death of a family member D. Develop a personal understanding of your own feelings about grief and death

D

Complex emotional, cognitive, social, physica, behavioral, and spiritual responses to loss and death. A. Grief B. Mourning C. Bereavement D. Normal Grief E. Complicated Grief

D

Describe Rando's process model of mourning. A. Denial, Anger, Bargaining, Depression, Acceptance. B. Numbing, Yearning/Searching, Disorganization/Dispair, Reorganization. C. Accept reality, Experience pain, Adjust, Move on with life. D. Recognize loss, React/express pain, Reminisce, Relinquish attachments, Readjust.

D

May exhibit self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

D

Which of the following is not an expected long-term outcome indicating effective grief interventions? A. Return of a sense of humor and normal life patterns B. Renewed or new personal relationships C. Decreased inner pain D. Improved ability to make decisions

D

Which of the following statements, if made by a dying client, would indicate that spiritual needs most likely are being met? The individual states that: A. "The afterlife is the best place." B. "I no longer fear pain." C. "Family is the most important part of my life." D. "There have been many positive things about my life, and I have hope.

D

You are caring for a patient who is depressed because their ownly child has gone away to college. The nurse will assess this type of depression as: A. Actual loss B. Perceived loss C. Situational loss D. Maturational loss

D

While the nurse is caring for a client with severe cardiac disease, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which nursing action is appropriate?

Notify the primary health care provider (PHCP) of the client's request.

Dysfunctional; the grieving person has a prolonged or significant time moving forward after a loss. A. Grief B. Mourning C. Bereavement D. Normal Grief E. Complicated Grief

E

Person is unaware of disruptive behavior as a result of loss. A. Disenfranchised grief B. Delayed grief C. Ambiguous loss D. Exaggerated grief E. Masked grief F. Anticipatory grief

E

The nurse is supervising the postmortem care of a client. Which action by the assistive personnel (AP) performing the care is appropriate?

Elevates the head of the bed 30 degrees as soon as possible after death

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know they will not be abandoned by the nurse.

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention?

Encourage the client to maintain maximum self-control.

A nurse is preparing a health promotion course for a group of middle adults. Which fo the following strategies should the nurse recommend? (Select all that apply).

Eye examinations every 1 to 3 years DXA screening for osteoporosis Increase intake of carbohydrates in the diet Screening for depressive disorders

The nurse is working in a pediatric outpatient clinic. There is an 8-year-old child whose grandfather has just died. Based on the developmental level of the child, what type of response would the nurse anticipate?

I was bad at school and talked back to Mom. That's why Grandpa died

The hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine?

It helps to reduce anxiety and oxygen consumption.

The nurse is caring for a client with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority?

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which fo the following physiologic functions? (Select all that apply).

Metabolism Gastric secretions Glomerular filtration

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply.

The nurse encourages the client and family to identify and discuss feelings openly. The nurse assists the client and family in carrying out spiritually meaningful practices. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death. Which finding indicates to the nurse that the standard for ongoing care has been maintained?

Urine output 100 mL/hr

Which person is most likely to suffer from a maturational loss?

a college students who has never been away from home goes to Europe to study

10. A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e. Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f. Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision.

a. Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b. Explain to the family what will happen at each phase of the weaning and offer support. c. Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified.

15. A 70-year-old female patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker? a. Patient b. Daughter c. Doctor d. Ethics consult team

a. Patient

2. A nurse who cared for a dying patient and his family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow.

a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. f. The patient's daughter writes a poem expressing her sorrow.

13. A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy? a. The nurse places the patient in a sitting position while the family visits. b. The nurse places identification tags on both the shroud and the ankle. c. The nurse removes soiled dressings and tubes. d. The nurse makes sure a death certificate is issued and signed.

a. The nurse places the patient in a sitting position while the family visits.

8. A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association regarding assisted suicide? a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death. b. The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die." d. The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death.

The nurse enters the room and the family is standing around the dying patient loudly praying and chanting. The wife invites the nurse to join in. What should the nurse do first?

assess effects of the activity on the patient

The UAP tells the nurse that the dying patient's family keeps calling for assistance with minor tasks that that could easily do for the patient. What should the nurse do?

assess the family's desire and ability to participate in the care of the patient

Which nursing action is most likely to be affected by the patient's advance directives?

assisting the provider to intubate for respiratory arrest