questions

Decreased muscle tone

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?

Bone pain, slurred speech, pruritus

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Cheyne stokes respirations

A client has been receiving palliative care for the past several weeks in light of her worsening condition after a series of strokes. You notice the patient "stops breathing for a while then breathes fast and hard, and then stops again." This client is experiencing___.

Maintain eye contact

A client is cognitively impaired. What techniques can the nurse use to facilitate communication?

The client is a fall risk and must be near the nurses station for safety

A client with Alzheimer's disease has been transferred to the medical unit accompanied by the spouse. The client is cognitively impaired and confused. The nurse assigns the client a room with low lighting near the nurse's station. Which of the following best explains the reason for this room assignment?

Apraxia

A client with a diagnosis of Alzheimer's disease has the inability to use objects properly. The nurse caring for this client recognizes this as a symptom of neurocognitive disease called __________________.

Place the document on the patients medical record

A competent older adult patient has an advance directive that expresses the patient's desire to avoid resuscitation and heroic life support measures. The patient's family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation?

Patterns for dealing with grief

A nurse has been working full-time with terminally ill clients for 3 years. he has been experiencing irritability and mixed emotions when expressing sadness since 4 of his clients died on the same day. To optimize the quality of his nursing care, he should examine his own

Apply fresh linens and place a clean gown on the body, remove all equipment from the bedside, dim the lights in the room

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply)

A client who has terminal cancer and needs assitance with pain management

A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?

Dialysis disequilibrium

A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications?

Electrolyte imbalance

A nurse is caring for a client in the hospital with delirium. The nurse recognizes that this could be caused by which of the following?

Improve her quality of life, focus on reducing the severity of disease symptoms

An 80-year-old female client is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to, (select all that apply)

Personality, mobility, speech

In addition to disturbances in cognition and orientation, individual's with Alzheimer's disease may also show changes in which of the following? Select all that apply

Amyloid beta plaques and neurofibrillary tangles

Mrs. G has been diagnosed with a neurocognitive disorder due to Alzheimer's disease. The nurse recognizes this disorder is associated with the presence of which of the following?

Respirations may sound loud and wet during this stage

The nurse is providing care to a patient who is approaching death. Which family member statement regarding the physical and psychological changes associated with death is reflective of this late stage?

Vitamin e

The nurse recognizes that supplementation with which vitamin has been found to help with the symptoms of Alzheimer's disease?

MMSE

The nurse recognizes this is an evaluation tool to diagnose and evaluate the progression of cognitive impairment.

You may want to talk with a respite provider who can occasionally care for your child

The parents of a child with autism talk with a nurse about their feelings of being overwhelmed in caring for their child. They state that they do not get a break from their child, the child's needs are almost more than they can handle, and they are considering divorce. Which of the following initial responses from the nurse is most appropriate?

Unknown

the nurse recognizes which as the probable cause of AD

The higher level thinking process you use to control and coordinate your other cognitive abilities

executive function refers to

I dont think that i can live without my husband to take care of me

The hospice nurse visits with the wife of a dying client. The nurse is most concerned if the patient's wife makes which statement?

Inform her that her husband can retain his provider when transitioning to hospice care, inform her that a diagnosis of cancer is not required for hospice care

The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care, but she thinks that hospice is only available for cancer patients and would require a change in healthcare providers. Which responses by the nurse are appropriate? Select all that apply.

Cheyne stoke respirations

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

BUN 45 and creatinine 8

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

pH 7.25, HCO3 19 mEq/L, PaCO2 30mmHg

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A low protein diet reduces the risk for uremia

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make?

I should place a cool mist humidifier in the room

A nurse is teaching the parent of an infant who has Down Syndrome. Which of the following statements by the parent indicates an understanding of the teaching?

Administer antiemetic drugs before meals as ordered

The nurse finds that a terminally ill client is experiencing nausea and vomiting. Which would be an appropriate nursing action?

Engages in repetitive behaviors

The nurse is assessing a 3 year old child for symptoms of autism. Which assessment findings would lead the nurse to question the diagnosis?

Do you have any specific dietary preference that affect your care

The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question does the nurse include?

Pain

The nurse is assessing the patient for palliative care. When assessing the physical aspects of care, which should the nurse include?

I will listen and respond as the family talks about their childs life

The nurse is caring for a child who has a terminal illness and reviews palliative care with a nurses aide. Which of the following statements by the nurses aide indicates understanding of this review?

Depression

The nurse is caring for a client whose spouse died two weeks ago. The nurse observes that the client does not engage in active conversation and avoids eye contact. Which stage of grief is the patient in?

Ensuring the environment is safe to prevent from injury

The nurse is caring for a client with Alzheimer's Disease. The primary nursing intervention in working with this client is which of the following?

Allowing the fam to spend time with the deceased patient, retaining all catheters and tubes in the body, allowing the family to pray with the body before transport

The nurse is caring for a patient who died unexpectedly, and an autopsy has been ordered. In providing postmortem care, which actions by the nurse are correct? Select all the apply.

Developmental delays

The nurse is caring for a two year old client with Down Syndrome. The nurse recognizes this client most likely has _____________________.

I can only give the pain meds when requested

The nurse is educating the family of a patient in hospice care who is receiving morphine for pain because of a terminal illness. Which statement by the family member indicates the need for further teaching?

Palliative care

The nurse is providing care for a patient receiving curative care who is experiencing chronic pain as a result of cancer. Which type of care should the nurse plan for on discharge for this patient?

Preparing the patient and the family for the process of dying

Which concept exemplifies a well-managed death experience for a patient with a terminal diagnosis and the patient's family members?

Uncontrolled pain, hypoglycemia, renal failure, hypoxia

Which of the following are precipitating factors that could lead to delirium? Select all that apply

Multiple small strokes

Which of the following factors is not associated with increased incidence of neurocognitive disorder due to Alzheimer's disease?

Encourage him and give him plenty of time to perform as many adls as possible independently, assist with step by step instructions

Which of the following interventions is most appropriate in helping a patient with Alzheimer's disease with his ADL's? Select all that apply