PREPU Final Exam
The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning? A. "All efforts will be taken to make sure your loved one is comfortable and out of pain." B. "If you change your mind after we remove the breathing tube, just tell us and it will be reinserted." C. "Your loved one will not feel or be aware of anything that is happening once the breathing tube is removed." D. "Once the endotracheal tube is removed, your loved one will no longer be able to breathe."
"All efforts will be taken to make sure your loved one is comfortable and out of pain." Explanation: A common and valid concern of families during terminal weaning is to make sure the client is not suffering. As such, the nurse's role is to educate the family regarding comfort measures, such as pain medication and additional sedation. It is inaccurate to tell the family that the client will no longer be able to breathe once the tube is removed. The client may continue breathing for several hours to days. When a decision is made to terminate mechanical ventilation, it should be clear that reintubation is no longer an option and death is inevitable. The nurse must be honest with the family, as the client may be aware of loved ones in the room and talking to the client is encouraged.
A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse? "Once you've started treatment, it's important to continue." "Have you discussed this with your health care provider?" "Can you tell me about why you've made this decision?" "Does your family agree with this decision?"
"Can you tell me about why you've made this decision?" Explanation: Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings. A competent client is not required to continue with treatment that has been initiated. The other options are closed-ended and stop any further conversation.
A nurse practitioner is teaching the student about sexual health and is evaluating the student's knowledge of sexual identity. The practitioner knows that the student understands when the student says which of the following? "Gender role behavior is the behavior a person conveys about being male or female." "Gender identity refers to the preferred gender of a person's partner." "Biologic sex is the inner sense a person has of being male or female." "Sexual orientation is the term used to denote chromosomal sexual development."
"Gender role behavior is the behavior a person conveys about being male or female." Explanation: Sexual identity encompasses a person's self-identity, biologic sex, gender identity, gender role behavior or orientation, and sexual orientation or preference. Gender role behavior is the behavior a person conveys about being male or female. Biologic sex is the term used to denote chromosomal sexual development. Gender identity is the inner sense a person has of being male or female. Sexual orientation refers to the preferred gender of a person's partner.
The cardiac nurse, who has been caring for a hospitalized, terminally ill client for 3 days, finds that the client has expired. The nurse manager knows that the nurse can legally care for these clients when the nurse makes which statement? "Hospitals are mandated to notify transplant programs of potential donors." "Organs are only retrieved from totally brain-dead clients." "I need to notify the coroner of all deaths." "The health care provider will give consent for the autopsy."
"Hospitals are mandated to notify transplant programs of potential donors." Explanation: The scarcity of organs has resulted in legislation mandating hospitals to notify transplantation programs of potential donors. Consent for autopsy is legally required, usually from the closest surviving family member. It is usually the physician's responsibility to obtain permission for an autopsy. If death is caused by accident, suicide, homicide, or illegal therapeutic practice, or if it occurs within 24 hours of admission to the hospital, the coroner must be notified. Organs can be obtained from brain-dead clients and non-heart-beating cadavers.
A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse? A. "We can discontinue the service for a period of time and then when your family member gets worse, readmit them." B. "Unfortunately, we are unable to continue services past the 6 month period of time." C. "We can admit your family member to the hospital for treatment and they can reinstate the hospice benefits." D. "I will contact the health care provider to extend services since your family member meets the criteria."
"I will contact the health care provider to extend services since your family member meets the criteria." Explanation: Hospice care is generally provided to clients that have 6 months or less to live, although they are not automatically discharged when they reach 6 months after having been admitted to hospice care. The client may still receive care as long as the health care provider certifies that the client continues to meet the criteria for hospice services. The client should not be admitted to the hospital since the acceptance of palliative comfort care is required to qualify for hospice services. Based on the provided information, there is no need to admit the client to the hospital, and hospital admission may result in termination from the program due to the provision of non-palliative care.
The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client? A. "This is so sad and I feel so bad that you are in this situation." B. "It sounds as though you are most concerned about how your children will feel." C. "This just is not fair at all and I do not understand why this is happening to you." D. "I am so sorry that I am crying with you when you need my support the most."
"It sounds as though you are most concerned about how your children will feel." Explanation: The nurse is demonstrating empathy when reiterating what the client is saying. This helps the nurse become effective at providing for the client's emotional needs while maintaining detachment. The other responses indicate that the nurse is feeling sympathy for the client, which includes feeling as emotionally distraught as the client. While this may be an unavoidable response, it may not help the client move through the grieving process as effectively.
A gerontology nurse is discussing sexual dysfunction with an older adult male client. The nurse determines that the education has been effective when the client states: "Erectile dysfunction, caused by diabetes, has no treatment." "Malnutrition may cause impotence." "Antihypertensive medication will not affect sexual function." "I need to be able to walk a mile in order for sexual intercourse to not be dangerous."
"Malnutrition may cause impotence." Explanation: Factors that contribute to sexual dysfunction in the older adult are as follows: use of medications, especially antihypertensive medications; age-related metabolic disorders such as anemia, diabetes, malnutrition, and fatigue (may cause impotence). Sexual intercourse and similar forms of sexual expression are not considered dangerous for anyone able to walk around a room. Erectile dysfunction has treatments such as a penile prosthesis or pharmacologic management.
During an interview of the client at the community clinic, the nurse finds that the client is providing care for a parent, who is terminally ill. Which statement by the client indicates anticipatory grieving? A. "I do not think my parent really has cancer. I think my parent needs to get a third opinion." B. "My parent is suffering with cancer and death will be a relief of the pain." C. "There is no way I can stay in the hospital because my parent is sick." D. "It is fine if my parent dies. We have not been close for years."
"My parent is suffering with cancer and death will be a relief of the pain." Explanation: Anticipatory grief is the characteristic pattern of psychological and physiologic responses a person makes to the impending loss of a significant person. The client's statement, "My parent is suffering with cancer and death will be a relief of the pain," is an example of anticipatory grief and is intended to facilitate coping when death occurs. The client's statement, "There is no way I can stay in the hospital because my parent is sick" demonstrates empathy for the parent and denial of a personal need for treatment. Denial is apparent when the client suggests the parent's diagnosis is incorrect. Denial is also apparent when the client relates it is "fine" if the mother expires because they were not close.
The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information? A. "The RAS serves to monitor and regulate incoming sensory stimuli." B. "The RAS is a well-defined network that extends from the hypothalamus to the medulla." D. "To receive stimuli and respond appropriately, the brain can be in any state of arousal." E. "The RAS allows all impulses to reach the cerebral cortex and to be perceived."
"The RAS serves to monitor and regulate incoming sensory stimuli." Explanation: The RAS serves to monitor and to regulate incoming sensory stimuli. To receive stimuli and respond appropriately, the brain must be alert or aroused. The RAS, a poorly defined network, extends from the hypothalamus to the medulla. Nerve impulses from all the sensory tracts reach the RAS, which then selectively allows certain impulses to reach the cerebral cortex and to be perceived.
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. "The client will have to go to an inpatient hospice unit in order to receive palliative care." C. "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." D. "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops."
"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." Explanation: Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.
When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response? A. "Have you talked with your spiritual leader about your fears?" B. "This must be very difficult for you." C. "I'm sure you are angry and sad." D. "Yes, this is a terrible diagnosis you've received."
"This must be very difficult for you." Explanation: The nurse should use statements with broad openings, such as "This must be difficult for you," to allow the client to continue expressing concerns and to acknowledge the client's feelings. This facilitates communication and allows the client to choose the topic or manner of response during this stage of the grieving process. Assuming the client is angry and sad or indicating that this is "a terrible diagnosis" is not an appropriate way to promote coping. The nurse should automatically assume a spiritual leader is desired.
An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement? A. "I will get you another meal." B. "Would you like another meal?" C. "It is okay to eat. The food is not poisoned." D. "What makes you think the food is poisoned?"
"What makes you think the food is poisoned?" Explanation: The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.
The nurse is planning strategies to increase sensory stimulation for clients in isolation. Which considerations should the nurse keep in mind? Select all that apply. A. The amount of stimuli different individuals consider optimal is constant. B. An individual's culture may dictate the amount of sensory stimulation considered normal. C. It is recommended that medically fragile infants have greater light and visual and vestibular stimulation. D. Sensory functioning tends to decline progressively throughout adulthood. E. Sensory functioning is established at birth and is independent of stimulation received during childhood. F. Different personality types demand different levels of stimulation.
-Sensory functioning tends to decline progressively throughout adulthood. -An individual's culture may dictate the amount of sensory stimulation considered normal. -Different personality types demand different levels of stimulation. Explanation: Because sensory functioning tends to decline throughout adulthood, it is especially important for the nurse to plan stimulating activities for these clients in isolation. Culture and personality guide the amount and level of sensory stimulation necessary for individuals. The amount of stimuli different individuals consider optimal is not constant; this could lead to overstimulation. Sensory functioning develops over time; it isn't established at birth. Medically fragile infants should have a decrease in environmental stimulation.
A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis? A. Anxiety B. Physical immobility C. Overdistention D. Compromised
Anxiety Explanation: Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. It is also the only option related to the client's experience to the new experience of being hospitalized. Compromised is a descriptor; physical immobility is a risk factor; overdistension is a related factor.
The nursing process includes step(s)? Select all that apply. A. Implement B. Prescribe C. Plan D. Evaluate E. Assess
Assess Plan Implement Evaluate Explanation: The nursing process consists of assessing the client, planning the client's care, implementing the planned interventions, and evaluating the effectiveness of those interventions. Prescribing is not a part of the nursing process.
An older adult client has been hospitalized for 8 days following skin grafting. The nurse suspects the client is experiencing sensory deprivation. Which strategy will be most effective in this situation? A. Assess and reorient the client to time, place, and person as needed. B. Request a prescription for risperidone injection. C. Consult a clinical psychiatrist for continued care. D. Place the client in soft restraints to prevent injury.
Assess and reorient the client to time, place, and person as needed. Explanation: The most effective strategy for the nurse to use in this situation is to assess orientation and reorient the client as needed. Consulting a clinical psychiatrist may not be necessary, as reorientation and sensory stimulation are effective interventions. Requesting a medication used to manage schizophrenia is not appropriate, as the client is experiencing sensory deprivation. Restraints are a last resort and other measures should be attempted first.
An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? A. Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis B. Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate C. Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency D. Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence
Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Explanation: The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.
Which action(s) is appropriate to safely bathe an older adult client? Select all that apply. A. Carefully monitor water temperature. B. Use vigorous rubbing motions when drying the skin to increase circulation. C. Use a tub/shower seat if balance problems are present. D. Pour scented bath oils into the tub to improve dryness of the skin and decrease odors. E. Provide the client a long-handled shower brush or attachment if experiencing limited mobility.
C. Use a tub/shower seat if balance problems are present. A. Carefully monitor water temperature. E. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. Explanation: Several considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using nonskid mats and using a tub/shower seat. Also, care is taken to promote independence by providing the client with long-handled shower brushes or attachments if there is limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. The nurse should use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. The nurse should avoid using perfumed soaps and lotions, as well as avoid rubbing the skin when drying. The nurse should use gentle patting motions to maintain skin integrity.
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? A. Ask the client if he left his earplugs in his ears. B. Use facial expressions and sign language to communicate. C. Speak to the older adult client in a high-frequency tone of voice. D. Check the client's ear canals for cerumen.
Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.
A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting? A. Stupor B. Coma C. Somnolence D. Asleep
Coma Explanation: Unconscious states include asleep, stupor, and coma. Coma is characterized by an inability to be aroused and no response to stimuli. A client in a stupor can be aroused by extreme and/or repeated stimuli. Sleep is a naturally recurring state of mind and body, characterized by unconscious, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles, and reduced interactions with surroundings. During sleep the client can be awakened.
A female nurse is giving a complete bed bath to a young male client. The nurse notices the client has an erection. Which action will the nurse take? Scold the client for feeling attraction. Advise the client that the nurse will tell his parents. Continue bathing the client. Stop bathing the client and state the nurse will return when the client stops reacting.
Continue bathing the client. Explanation: An erection may occur in response to a full bladder, fantasy, or touch. Exposure of the male client by the nurse may cause an erection during a bed bath. An erection is a normal physiological response and not something the man can voluntarily control. It does not mean the client is attracted to the nurse. By continuing on with the bath the nurse creates a sense of normalcy. There is no need to tell the client's parents about this normal reaction.
The hospice nurse is visiting the wife of a client who died 10 months ago. The wife states, "My life is meaningless since my husband died." The nurse recognizes that the client is in which stage of grief? A. Protest B. Disorganization C. Shock D. Reorganization
Disorganization Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of deceased, be comfortable when remembering the deceased, and return to previous level of ability.
The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client? A. Using earplugs when using loud machinery B. Practicing oral care three times a day C. Eliminating disturbing odors with adequate ventilation D. Protecting the skin from extremes in temperature
Eliminating disturbing odors with adequate ventilation Explanation: Olfactory or smell disturbances can be aided by eliminating disturbing odors with adequate ventilation. Earplugs help those with auditory disturbances. Oral care is useful for those with taste disturbances. Protecting the skin is important for those with tactile disturbances.
A client has a history of poorly controlled diabetes. Which health concern will the nurse discuss with the client? Retarded ejaculation Premature ejaculation Erectile dysfunction Sexually transmitted infections
Erectile dysfunction Explanation: Diabetes is a significant risk factor for erectile dysfunction. The constant elevation of blood sugar in diabetes affects the vascular contraction of male clients. Diabetes does not create an appreciably increased risk of developing sexually transmitted infections, although clients with diabetes have an increased susceptibility to infections of all kinds. Retarded or premature ejaculation is less likely, as these problems do not have a vascular etiology.
The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply. A. Gurgling sounds emanating from the client's throat with each breath B. Distended abdomen with last bowel movement documented 7 days ago C. A regular apical pulse of 90 beats/minute D. Systolic blood pressure which rose from 100 to 110 mm Hg E. Cyanotic nail beds in hands and feet bilaterally
Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago Cyanotic nail beds in hands and feet bilaterally Explanation: Signs of an impending death include noisy respirations, abdominal distention, constipation, and cyanosis of the extremities. The pulse may be slow and/or irregular. The systolic blood pressure would be decreasing, not increasing.
A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? A. Risk B. Health promotion C. Syndrome D. Problem-focused
Health promotion Explanation: A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions or life processes. A syndrome nursing diagnosis is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions.
The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? A. Syndrome nursing diagnosis B. Actual nursing diagnosis C. Health promotion nursing diagnosis D. Risk nursing diagnosis
Health promotion nursing diagnosis Explanation: Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.
A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? A. Disturbed Self-Concept related to pancreatic cancer diagnosis B. Knowledge Deficit: Cancer treatment options related to new diagnosis C. Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis D. Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Explanation: The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.
A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate? A. Extended B. Hospice C. Respite D. Palliative
Hospice Explanation: Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones, often provided in the client's own home. Because the client is near the end of life, hospice care would be the most appropriate referral. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults, to give them some time away from the responsibilities of day-to-day care. This type of care would not be appropriate for this client because the client has been hospitalized and wants to be with family. Extended-care services provide medical and nonmedical care for people with chronic illnesses or disabilities. Extended care occurs outside the home, however, which is not what the client desires. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering. Palliative care alone is not as appropriate as hospice care in this case, given that the client is near the end of life.
The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication? A. Speak in a loud voice over the volume of the television set. Obtain the client's attention by calling out the client's first name. Remove the COVID protection face mask while speaking with the client. Identify oneself by name and title with each entry into the client's room.
Identify oneself by name and title with each entry into the client's room. Explanation: To facilitate communication with an older client who has visual and hearing deficits, the nurse identifies oneself by name and title each time the nurse enters the client's room. This assists with the orientation of the client who can place the interaction into proper perspective. The nurse does not remove one's face mask. The face mask is to minimize the risk for COVID for both the nurse and the client. The nurse with permission of the client would decrease the volume of the television set, or even turn the television set off, so as to not compete with the television program. This will facilitate hearing. People with hearing deficits have difficulty distinguishing simultaneous sounds from each other. The nurse will call the client by the client's preferred name. This demonstrates respect for the client. The client's name preference may not be the client's first name.
A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem? A. Chronic confusion B. Impaired memory C. Disturbed sensory perception D. Acute confusion
Impaired memory Explanation: Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? A. Instruct the client and family in wound care. B. Discuss discharge plans with the client. C. Inform the client what to expect after the surgery. D. Teach the client about dietary restrictions during recovery.
Inform the client what to expect after the surgery. Explanation: If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.
A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? A. Repeat each direction or question in different terms in order to maximize understanding. B. Use vocabulary and concepts that are as simple and unambiguous as possible. C. Minimize background noises and ensure that lighting is adequate to see the nurse's face. D. Use written communication whenever possible in order to minimize the client's frustration.
Minimize background noises and ensure that lighting is adequate to see the nurse's face. Explanation: When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.
Which is the most appropriate example of the assessment phase of the nursing process? A. Evaluating the temperature of a client given medication for a fever B. Including a nursing diagnosis of Acute Pain in the client's plan of care C. Palpating a mass in the right lower quadrant of the abdomen D. Documenting the administration of a medication provided for pain
Palpating a mass in the right lower quadrant of the abdomen Explanation: Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.
A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care? Occupational therapy Physical rehabilitation Relief from physical, mental, and spiritual distress Provision of a dignified death experience
Relief from physical, mental, and spiritual distress Explanation: The chief focus of palliative care is relief or management from physical, mental, and spiritual distress. The goal of palliative care is to prevent and relieve suffering by early assessment and treatment of pain and other physical problems (such as difficulty breathing, nausea, fatigue, and problems with sleeping). Like hospice care, palliative care is provided by an interdisciplinary team. Physical rehabilitation and occupational therapy would be the goal of home care, moving the client from the functional level at discharge from the hospital to a higher level of functioning, closer to the level prior to the hospitalization. Provision of a dignified death experience would be the goal of hospice.
A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? A. Risk for Infection related to community contamination B. Deficient Community Health related to chemical plant C. Risk for Community Contamination related to possible environmental pollution D. Knowledge Deficit related to effects of chemical plant pollution
Risk for Community Contamination related to possible environmental pollution Explanation: The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse. Knowledge Deficit is not appropriate because it has too narrow a focus. Deficient Community Health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for Infection has a very narrow focus. The etiology of community contamination has not been proven.
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? A. Risk for Injury related to substance use B. Risk for Falls related to immobility C. Risk for Poisoning related to poor eyesight and the inability to read medication labels D. Altered Sensory Perception related to decreased visual acuity
Risk for Poisoning related to poor eyesight and the inability to read medication labels Explanation: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of the multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance use in this client.
An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being? A. Clients would be put in a state of sensoristasis. B. Sensory adaptation occurs in the intensive care unit. C. Increased noise levels depress the reticular activating system. D. Sensory overload can cause anxiety and irritability.
Sensory overload can cause anxiety and irritability. Explanation: Sensory stimulation in the environment affects sensory perception. The lights, sounds, and action in the ICU may put the client in a state of sensory overload, which results in irritability, anxiety, and difficulty concentrating. Sensoristasis is the state of optimal arousal. Sensory adaptation occurs when the brain stops perceiving constant stimuli. The RAS, or reticular activating system, brings together information from the brain with information from the sense organs.
A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care? A. Apply hairpins and clips. B. Avoid replacing dentures in the mouth. C. Place a rolled towel under the head. D. Cleanse drainage from the skin.
The client did not have any recent medical consultation. Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.
A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? A. The client states, "I hope that I am able to attend my daughter's wedding." B. The client makes funeral plans. C. The client states, "I am sure the doctors have misdiagnosed me." D. The client asks about hospice services.
The client states, "I am sure the doctors have misdiagnosed me." Explanation: Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.
Which factor is most likely to contribute to the nurse making a diagnostic error? A. The client's subjective and objective data are congruent. B. The client withholds information during the client assessment. C. The subjective and objective data point to a specific health issue. D. The client expands on information previously provided.
The client withholds information during the client assessment. Explanation: Diagnostic errors occur when the database is incomplete. Subjective and objective data that cluster together and point to a specific health problem decrease the likelihood of diagnostic errors. The risk of making a diagnostic error decreases when the client's subjective and objective data are congruent and when the client expands on information previously provided.
A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death? The frequency of urination decreases. The arms and legs are warm to touch. The client's breathing becomes noisy. The client is calm and peaceful.
The client's breathing becomes noisy. Explanation: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.
"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse? "It is not normal. Your mother needs to see a therapist about her grief." "In fact, the more that someone cries about a loss, the better they're dealing with it." "The inability to talk about your dad without crying, even after a year, is still considered normal." "Did your mother cry a lot before your father died?"
The inability to talk about your dad without crying, even after a year, is still considered normal." Explanation: Normal responses to bereavement after 1 year include the inability to speak of the deceased without intense emotion, clinical signs of depression, and feelings of meaninglessness. Increased crying does not necessarily signal increased coping, however.
The nurse is assessing the sexual health of a female client age 20 years. During the interview, the client says, "I feel that my vaginal opening constricts whenever I am about to have intercourse. I seem to have no control over it." What would the nurse use when documenting the client's report? A. Celibacy B. Dyspareunia C. Vaginismus D. Orgasmic dysfunction
Vaginismus Explanation: The client is experiencing an involuntary contraction of the muscles surrounding the vaginal orifice; this should be documented as vaginismus. Dyspareunia is painful intercourse. Difficulty achieving orgasm is documented as orgasmic dysfunction. Abstention from sexual intercourse is documented as celibacy.
A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model? acceptance bargaining denial depression
bargaining Explanation: Bargaining is a psychological mechanism for delaying the inevitable, usually by negotiating with a higher power. All other choices are incorrect.
"In hospice care, the nurses make most of the care decisions for the clients." Explanation: The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.
consulting the family member prior to performing post-mortem care Explanation: Only family members may touch or wash the body of a deceased individual who practiced the Islamic faith, so the nurse should ask for permission prior to providing post-mortem care. The family may choose to remain, but the nurse will not be allowed to wash the body. It will be the nurse's responsibility to arrange for transport to the funeral home after care is rendered by the family.
A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes: A. encouraging clients to use earphones adjusted to a loud volume for hearing. B. demonstrating or pantomiming ideas to clients with hearing impairments. C. cleaning the clients' ears daily with a cotton-tipped applicator. D. speaking loudly and directly to clients with hearing impairments.
demonstrating or pantomiming ideas to clients with hearing impairments. Explanation: For hearing-impaired clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communication, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.
The nurse is assessing a client recently diagnosed with terminal lung cancer who states, "This can't be happening to me. Maybe the doctor made a mistake." Which stage of death and dying is the client exhibiting? A. anger B. denial C. depression D. bargaining
denial Explanation: In the denial stage, the client denies the reality of death and may repress what is discussed. The client may think the doctor made a mistake in the diagnosis or that his or her records were mixed up with another client's records. In the anger stage, the client demonstrates rage and hostility. In the bargaining stage, the client tries to barter for more time. In the depression stage, the client demonstrates a period of grief before death characterized by crying and not speaking much.
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 sign would the nurse include in this education plan? A. increased urinary output B. difficulty swallowing C. decreased pain D. increased sensory stimulation
difficulty swallowing Explanation: A sign that death is approaching is the client's difficulty in swallowing. People who are dying do not experience decreased pain. They may not be in a position to report pain; therefore, the caregiver should observe the client closely. Urinary output decreases when a person is approaching death due to system failure and limited intake. The client approaching death has decreased sensory stimulation.
The nurse needs to understand the teaching-learning process when administering A. educational interventions. B. psychosocial interventions. C. physician-initiated interventions. D. technical interventions.
educational interventions. Explanation: Educational interventions require the application of the teaching-learning process. The other interventions listed would not, as their primary goal is not to educate the client.
What is the most important goal of care for the dying client who is receiving comfort care? A. ensuring family members are present at the bedside B. using a feeding tube to provide nutrition C. providing a comfortable, dignified death D. identifying appropriate coping mechanisms
providing a comfortable, dignified death Explanation: Clients or their surrogates may request a comfort-measures-only order, which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. Using a feeding tube and identifying appropriate coping mechanisms are not characteristics of comfort care. The presence of family members at the bedside is important for any dying client and is not specific to comfort care.
A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his: A. reticular activating system (RAS). B. cerebellum. C. prefrontal cortex. D. limbic system.
reticular activating system (RAS). Explanation: The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.
A client who is blind is said to be experiencing: A. sensory overstimulation. B. sensory deficit. C. sensory overload. D. sensory deprivation.
sensory deficit. Explanation: Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.
The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care? A. to improve the client's and family's quality of life B. to support aggressive treatment for cure C. to provide physical support for the client D. The client may develop a separate plan with each discipline of the health care team.
to improve the client's and family's quality of life Explanation: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. A separate plan of care developed by the client with each discipline of the health care team is not the goal of palliative care.
Palliative care is a structured system for care delivery. What is its aim? A. to give traditional medical care B. to prevent and relieve suffering C. to bridge between curative care and hospice care D. to provide care while there is still hope
to prevent and relieve suffering Explanation: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? A. roller sheets B. foot boards C. foot splints D. trochanter rolls
trochanter rolls Explanation: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for this client.
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? A. the antecubital fossa and popliteal space B. underneath the breasts and in between skinfolds C. underneath the fingernails and toenails D. the inner and outer canthus of each eye
underneath the breasts and in between skinfolds Explanation: Skinfold areas may be sources of odor and skin breakdown if not cleaned and dried properly. The antecubital fossa (inner portion of arm) and popliteal space (behind the knee) are not skinfold areas that require cleaning. The eyes, toenails, and fingernails are not sources of odor.