A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Be honest with the client about their prognosis.

Include the client's input when setting treatment goals.

Keep an agreement made with the client to administer an antiemetic medication

Administer pain medication to the client on a routine schedule.

Answer and Explanation

The Correct Answer is B

A. Be honest with the client about their prognosis: Honesty is essential for building trust but does not alone promote autonomy. Autonomy specifically involves allowing the client to make informed decisions about their own care based on truthful information.

B. Include the client's input when setting treatment goals: Including the client’s input directly supports their autonomy by allowing them to actively participate in decisions about their care, treatments, and end-of-life goals, ensuring their personal values and wishes are respected.

C. Keep an agreement made with the client to administer an antiemetic medication: Honoring agreements builds trust and supports ethical practice but focuses more on fidelity than directly on promoting autonomy, which centers on the client’s decision-making role.

D. Administer pain medication to the client on a routine schedule: Providing pain management is important for comfort but does not by itself promote autonomy unless it involves client participation in deciding how and when the medication is administered.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Pneumonia: The preschooler is showing signs of shallow breathing, refusal to use the incentive spirometer, and slightly diminished breath sounds in the bilateral lower lobes, all of which increase the risk of developing pneumonia. Postoperative patients, especially young children, are vulnerable to pneumonia due to pain-limited deep breathing and poor pulmonary expansion.
Wound infection: Although there is some serosanguinous drainage at the incision site, the dressing remains dry overall, and there is no mention of redness, warmth, or purulent discharge typically associated with wound infection. Therefore, wound infection is not the primary concern at this point.
Ileus: Hypoactive bowel sounds are present, but they have been stable throughout the day without worsening abdominal distension or absence of bowel function. While ileus is a postoperative risk, the more pressing concern given the respiratory findings is pneumonia.
Shallow breathing: The child consistently shows shallow, unlabored respirations throughout assessments, which indicate limited lung expansion. Without effective use of the incentive spirometer and adequate deep breathing, shallow breathing places the child at high risk for pulmonary complications such as pneumonia.
Increasing temperature: Although the child's temperature rose slightly by 1600, it remains below 38° C (100.4° F), which is not typically classified as a fever. The minor temperature elevation could be related to inflammation rather than an infectious process at this stage.
Hypoactive bowel sounds: Hypoactive bowel sounds are expected in the early postoperative period, particularly following abdominal surgery due to the effects of anesthesia and manipulation of the bowel during surgery. While they should be monitored, they are not the primary finding indicating the most urgent complication in this situation.

A. Administer aspirin for fever B. Apply cooling blanket C. Monitor vital signs every 4 hours D. Place client on telemetry E. Palpate thyroid area to assess for hematoma

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

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A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a preschooler who is postoperative following an appendectomy. Complete the following sentence by using the lists of options. The pre-schooler is at risk for developing dropdown evidenced by the pre-schooler's dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse has reviewed the Vital Signs at 1000. For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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