A nurse enters a hospice patient’s room to perform an assessment after receiving the morning report.

The outgoing nurse reports that the patient is showing loss of appetite, swelling of the limbs, increased sleep, CheyneStokes respirations, and hallucinations.

Which of the following indicates the nurse understands the report?

Begin life-saving measures, such as a rapid response call.

Call the provider as these signs and symptoms are abnormal.

Rapid respirations that are unusually deep and regular, and are curative for the patient.

The nurse understands that these are impending signs of death and are normal

The nurse understands that these are impending signs of death and are normal.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

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Correct Answer is C

Explanation

Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.

A. You will have a steady and gradual decline in function. B. You must avoid stress and extreme fatigue because it can trigger a relapse. C. Your type of multiple sclerosis is the least common, making it difficult to manage. D. You should take your medications only during times of relapse.

Correct Answer is B

Explanation

Choice A rationale
This statement is not accurate. Relapsing-remitting multiple sclerosis (RRMS) is characterized by periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These episodes are followed by periods of remission, where the disease does not progress. Therefore, RRMS does not cause a steady and gradual decline in function.
Choice B rationale
This is the correct answer. Stress and extreme fatigue can trigger a relapse in RRMS1. Therefore, it is important for patients to avoid these triggers to manage their symptoms effectively.
Choice C rationale
This statement is incorrect. RRMS is the most common disease course at the time of diagnosis. It is not the least common type of multiple sclerosis.
Choice D rationale
This statement is not accurate. Medications for RRMS, known as disease-modifying treatments (DMT), are designed to reduce the frequency and severity of relapses. They are not intended to be taken only during times of relapse, but rather on an ongoing basis to manage the disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is getting ready to conduct a cranial nerve examination on a patient. What steps should the nurse take to examine cranial nerve XI (Spinal Accessory)?

Correct Answer is C

Explanation

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). What instruction should the nurse provide?

Correct Answer is B

Explanation

A nurse is caring for a patient who reports stress related to homelessness. The nurse should identify that the patient is experiencing which of the following types of stressors?

A nurse is teaching a class about sources of stress. The nurse should include that which of the following is an example of a psychological stressor?

a nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A nurse is instructing a newly licensed nurse about age-related changes to vision in older adult patients. Which of the following should the nurse include as an example of an expected age-related change?

A nurse is assessing an older adult patient who is experiencing age-related changes. Which of the following findings should the nurse expect?

A nurse is caring for a patient who is scheduled for a surgical procedure. The nurse is reviewing the patient’s electronic medical record. Which of the following findings places the patient at risk for a surgical complication? Select all that apply.

a nurse is providing care for a patient who reports experiencing flashbacks of a traumatic event that occurred a year ago. Which of the following stress-related disorders should the nurse identify that the patient is experiencing?