A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?
"You need to understand that you have very little time left."
"I will contact your provider to discuss your options."
"Enjoy the time you have and do the things you want to do."
"Hospice care is the best thing for you at this time."
The Correct Answer is B
A. "You need to understand that you have very little time left":
This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.
B. "I will contact your provider to discuss your options":
This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan
C. "Enjoy the time you have and do the things you want to do":
This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.
D. "Hospice care is the best thing for you at this time":
While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
Correct Answer is D
Explanation
A. A feeling of swelling in the feet:
Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.
B. Pain at the injection site:
Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.
C. A sudden decrease in heart rate:
An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.
D. A sharp decrease in blood pressure:
This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.
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