A client's wife has just learned that her husband is terminally ill. She 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.

Encourage the wife to share her feelings.

Offer reassurance that she is not alone.

Remind her that her husband may still live a long time.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because explaining that alternative treatment options may be helpful can be insensitive and unrealistic, as it may raise false hopes or imply that the husband's condition is not serious.

Choice B Reason: This is correct because encouraging the wife to share her feelings can help her cope with her grief and express her emotions in a supportive environment. The nurse should use active listening and empathic responses.

Choice C Reason: This is incorrect because offering reassurance that she is not alone can be dismissive and invalidating, as it may minimize her feelings or imply that she should not feel lonely.

Choice D Reason: This is incorrect because reminding her that her husband may still live a long time can be dishonest and inappropriate, as it may contradict the medical prognosis or imply that she should not prepare for his death.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.

Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.

Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.

Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.

A. Positions the head with the chin tilted slightly downward. B. Raises the head of the bed to 60 degrees. C. Places food on the unaffected side of the mouth. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is correct because 60degrees is not fully upright and may not provide optimal protection against aspiration. The client should ideally be positioned at 90 degrees during meals if tolerated indicating need for additional teaching

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is incorrect because resting before meals decreases fatigue and improves swallowing ability.

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A client's wife has just learned that her husband is terminally ill. She 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 client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is A

Explanation

A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Patient Data Exhibits Review H and P and nurse's notes. Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?