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. Measure the intake and output of a client who has received furosemide: Measuring intake and output is within the scope of practice for assistive personnel. The nurse remains responsible for interpreting the data and notifying the provider of any concerns.

B. Check a client's peripheral IV site for redness or swelling: Assessment of IV sites for complications such as infiltration, phlebitis, or infection requires clinical judgment and should be performed by licensed nursing personnel.

C. Assess the pain level of a client who has received acetaminophen: Pain assessment requires clinical judgment, interpretation of client responses, and knowledge of pain scales. Only licensed nurses should perform pain assessments and determine the effectiveness of interventions.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching involves understanding and communicating clinical concepts accurately. Even though it may seem routine, instructing or clarifying a gait technique requires nursing knowledge to ensure client safety and proper technique.

A. The grounding pad is positioned near the client's surgical site. B. The client is positioned to minimize pressure on the skin. C. The client is covered with a cooling blanket during surgery. D. The client's surgical site is shaved with a razor.

Correct Answer is B

Explanation

A. The grounding pad is positioned near the client's surgical site: The grounding pad for electrosurgery should be placed on a large, well-vascularized muscle mass away from the surgical site to ensure proper dispersion of electrical current and prevent burns. Placing it near the site increases risk of injury.

B. The client is positioned to minimize pressure on the skin: Proper positioning during surgery helps prevent pressure ulcers and nerve injuries by reducing prolonged pressure on bony prominences and delicate tissues, supporting a safe and therapeutic environment.

C. The client is covered with a cooling blanket during surgery: Maintaining normothermia is critical; cooling blankets can cause hypothermia, which increases the risk of complications such as infection and coagulopathy. Warm blankets or forced-air warming devices are preferred.

D. The client's surgical site is shaved with a razor: Shaving with a razor can cause microabrasions that increase the risk of surgical site infections. Clipping hair with electric clippers is the recommended practice to reduce infection risk.

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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

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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