A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?

Notify the health department of the client's condition.

Advise the client to weigh all possible outcomes prior to the decision.

Suggest to the family the value of genetic screening.

Explain that the family has a right to know of potential health problems.

Answer and Explanation

The Correct Answer is B

A)   This intervention is not appropriate because it violates the client's privacy and confidentiality. The health department does not need to be notified of the client's condition, as breast cancer is not a communicable disease or a public health threat. The nurse should respect the client's wishes and only share information with authorized persons or agencies.
B)   This intervention is appropriate because it respects the client's autonomy and encourages informed decision-making. The nurse should advise the client to consider the benefits and risks of disclosing or withholding the diagnosis from the family, and how it may affect their relationships and support systems. The nurse should also provide relevant information and resources to help the client make an informed choice.
C)   This intervention is not appropriate because it contradicts the client's decision and may cause confusion or distress for the family. The nurse should not suggest genetic screening to the family without the client's consent, as this may imply that they are at risk of developing breast cancer or other genetic disorders. The nurse should also avoid giving unsolicited advice or opinions that may interfere with the client's autonomy.
D)   This intervention is not appropriate because it imposes the nurse's values and beliefs on the client. The nurse should not explain that the family has a right to know of potential health problems, as this may imply that the client is wrong or selfish for withholding the diagnosis. The nurse should acknowledge and respect the client's perspective and preferences, and support them in coping with their condition.

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Correct Answer is D

Explanation

Choice A Reason: This is not the first action because it does not address the safety risk of smoking in the hospital. The nurse should document the occurrence after taking appropriate measures to prevent fire and injury.

Choice B Reason: This is not the first action because it does not stop the client from smoking in the bathroom. The nurse should obtain a prescription for a nicotine patch if the client agrees to quit smoking, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not ensure that the client will comply with the hospital smoking policy. The nurse should educate the client about the health hazards of smoking and the hospital rules, but this can be done later.

Choice D Reason: This is the best action because it alerts the authority figure who can intervene and enforce the hospital smoking policy. The nurse should notify the charge nurse as soon as possible to prevent fire and injury.

A. Monitor for impending signs of shock. B. Initiate enteric precaution procedures. C. Reduce light, noise and temperature. D. Encourage electrolyte supplements.

Correct Answer is A

Explanation

Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.

Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.

Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.

Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.

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Naxlex Comprehensive Predictor Exams

The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?

Correct Answer is D

Explanation

A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?

An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which role is responsible for coordinating the progression of this client's care through rehabilitation and discharge?

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

When triaging emergency room clients, which client should the nurse assess first?