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?

Offer reassurance that she is not alone.

Explain that alternative treatment options may be helpful.

Encourage the wife to share her feelings.

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

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.

Choice B reason: Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.

Choice C reason: Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.

Choice D reason: Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.

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Correct Answer is A

Explanation

Choice A reason: This is the correct instruction as it ensures that the injection is given in a well-perfused area with minimal risk of injury to major blood vessels or organs. The umbilicus should be avoided as it may harbor bacteria or cause discomfort.

Choice B reason: This is an incorrect instruction as it may result in a loss of medication or inaccurate dosing. The air bubble in the prefilled syringe should be left intact as it helps to seal the medication in the subcutaneous tissue and prevent leakage.

Choice C reason: This is an incorrect instruction as it may cause irritation or inflammation of the injection sites. The gluteal area should be avoided as it has a higher risk of hitting a nerve or blood vessel. The abdomen is the preferred site for low-molecular-weight heparin injections.

Choice D reason: This is an incorrect instruction as it may increase the risk of bleeding or bruising. The injection site should not be massaged or rubbed as it may dislodge the clot or damage the tissue.

A. Complete an adverse occurrence/incident report. B. Demonstrate proper securing of the restraints. C. Ensure that the restraints are not too tight. D. Initiate the facility's restraint flow sheet.

Correct Answer is B

Explanation

Choice A reason: Completing an adverse occurrence/incident report is not the most important action to implement. It may be necessary to document the incident later, but it does not address the immediate safety issue of the client.

Choice B reason: Demonstrating proper securing of the restraints is the best action to implement. It corrects the mistake made by the UAP and ensures that the client is not at risk of injury or entrapment. It also educates the UAP on the correct technique and policy for applying restraints.

Choice C reason: Ensuring that the restraints are not too tight is a relevant action to implement, but not the most important one. It is part of the ongoing assessment and care of the client who is restrained, but it does not correct the improper securing of the restraints to the bedside rails.

Choice D reason: Initiating the facility's restraint flow sheet is a required action to implement, but not the most important one. It is part of the documentation and evaluation of the client who is restrained, but it does not address the immediate safety issue of the client.

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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

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

Correct Answer is A

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?