A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?
"I can refer you to hospice care, and they can help you at home."
"You should discuss this with your family before making a decision."
"Do you understand that, without treatment, you will die?"
"Don't you think you are giving up too soon?"
The Correct Answer is A
The nurse should respect the client's autonomy and right to make decisions about their own care. Referring the client to hospice care is an appropriate response because it provides the client with support and care in their own home.
Options b, c, and d are not appropriate responses because they do not respect the client's autonomy.
Option b suggests that the client needs to discuss their decision with their family before making a decision, which may not be necessary or desired by the client.
Option c confronts the client with the reality of their illness in a potentially insensitive manner.
Option d suggests that the client is giving up too soon, which may not be an accurate or helpful assessment of the situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
Correct Answer is B
Explanation
An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.
a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not effective.
c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.
d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.
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