A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

"We can discuss this after completing the admission process."

"Your partner is in the denial stage of grief."

"You should discuss this problem with your family members."

"Your partner is experiencing an expected response to the dying process."

Answer and Explanation

The Correct Answer is D

A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.

B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.

C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.

D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.

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Correct Answer is A

Explanation

A. Chlorine bleach: Chlorine bleach is the recommended disinfectant for cleaning surfaces contaminated with Clostridium difficile spores. It is effective in killing these hardy spores that are resistant to many other disinfectants.

B. Chlorhexidine: Chlorhexidine is an antiseptic commonly used for skin cleansing, not for disinfecting environmental surfaces contaminated with C. difficile. It is ineffective against spores.

C. Triclosan: Triclosan is an antimicrobial found in some personal care products, but it is not suitable or approved for disinfecting surfaces in healthcare settings, especially against C. difficile.

D. Isopropyl alcohol: Alcohol-based disinfectants are ineffective against C. difficile spores. They do not have sporicidal activity and are not recommended for cleaning in cases of C. difficile infection.

A. Remove blankets from the client. B. Place cold packs on the client's axillae. C. Place a fan to blow air across the client. D. Give the client an alcohol sponge bath.

Correct Answer is A

Explanation

A. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.

B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.

C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.

D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.

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A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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