A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Explain that alternative treatment options may be helpful.

Remind the spouse that the client may still live a long time.

Offer reassurance that the spouse is not alone.

Encourage the spouse to share their feelings.

Answer and Explanation

The Correct Answer is C

C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.

A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.

D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.

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Correct Answer is ["B","C","D","E"]

Explanation

B. Hospice services can be initiated while the client is still in the hospital. Hospice teams can work alongside the hospital staff to provide care and support to the client and family during the transition to hospice care.
C. Hospice care emphasizes the involvement of family members in the care of the patient. The hospice team works with the patient and family to develop a personalized plan of care that addresses the physical, emotional, and spiritual needs of the patient and family members.
D. Hospice care focuses on providing comfort, maintaining dignity, and offering emotional support to patients with terminal illnesses and their families. The goal is to enhance quality of life and ensure that the patient's wishes and preferences are respected throughout the end-of- life process.
E. Hospice care can be provided in various settings, including the patient's own home, assisted living facilities, nursing homes, or inpatient hospice units. The option to receive care in the comfort of home is often preferred by many patients and families as it allows them to remain in familiar surroundings surrounded by loved ones.

A. Elevate the head of the bed to a 45-degree angle. B. Remove dentures or other oral appliance. C. Lift and lock the side rails in place. D. Apply the client's positive airway pressure device.

Correct Answer is D

Explanation

D. Severe obstructive sleep apnea poses a risk of respiratory compromise, particularly when compounded by the effects of opioid analgesics, which can depress respiratory drive. Applying the client's prescribed positive airway pressure (PAP) device, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), helps maintain airway patency and ensures adequate ventilation

A. It promotes better alignment of the airway, decreasing the likelihood of obstruction by the tongue or soft tissues. While this intervention is beneficial for managing OSA, it may not be the most critical intervention in this context.

B. Removing dentures or oral appliances may be necessary to prevent airway obstruction, especially during sleep when muscle tone is decreased. However, it is not the most critical intervention in this scenario

C. Securing side rails is important for client safety, especially in postoperative settings where clients may be at risk of falls. However, it does not directly address the client's obstructive sleep apnea or potential respiratory compromise from opioid administration.

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A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is D

Explanation

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

Which client assessment should the nurse perform during nasopharyngeal suctioning?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

The nurse is providing safety instructions to a client who is being discharged home with oxygen therapy. Which information provided by the client indicates understanding?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via masal cannula. The oxygen saturation is 89%. Which action should the nurse implement?