A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

"A social worker will address your concerns after discharge.”

"You should plan to go to a skilled nursing facility after discharge.”

"Your case manager will coordinate the resources you will need.”

"You will need hospice care until you feel stronger.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The nurse should not promise that a social worker will address the client's concerns, as this might not be accurate. While a social worker could be involved in the client's care, it's not their sole responsibility to address all concerns. The primary role of a social worker might be to provide emotional support and assistance with psychosocial issues.

Choice B rationale:

Suggesting that the client should plan to go to a skilled nursing facility after discharge might not be appropriate unless it's medically necessary. Terminal illness often requires a focus on palliative and hospice care rather than transferring to another care facility.

Choice C rationale:

This is the correct choice. The case manager plays a key role in coordinating the various resources and services the client will need after discharge. They ensure a smooth transition from the hospital to home, including arranging for home health care, medical equipment, and any other necessary services.

Choice D rationale:

Telling the client that they will need hospice care until they feel stronger is not appropriate. Hospice care is specifically for individuals with terminal illnesses who have a limited life expectancy. It is not about getting stronger but about providing comfort and support during the end-of-life period.

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Correct Answer is D

Explanation

Answer is: d. "Clients are the experts on their own pain."

Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.

Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.

Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.

Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.

A. A client who is scheduled for a tubal ligation in 2 hr and is crying. B. A client who has peripheral vascular disease and has an absent pulse in the right foot. C. A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F).

Correct Answer is B

Explanation

Choice A rationale:

A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.

Choice B rationale:

A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.

Choice C rationale:

A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.

Choice D rationale:

A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.

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A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

Nursing Test Bank

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