A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed.
Which of the following statements should the nurse make?
“Would you like to speak to a spiritual advisor?”
“Do you need a prescription for an antianxiety medication?”
“Would you like to talk to a counselor about advance directives?”
“Do you need information on hospice care?”
The Correct Answer is A
This statement shows respect for the client’s spirituality and offers support without imposing the nurse’s beliefs or values. Spirituality focuses on the significance and purpose of life and can help clients cope with depression and terminal illness.
Choice B is wrong because it implies that the client needs medication to deal with their feelings, which can be dismissive and insensitive.
Antianxiety medication may be appropriate for some clients, but it should not be the first option.
Choice C is wrong because it assumes that the client is ready to discuss advance directives, which may not be the case.
Advance directives are legal documents that specify the client’s wishes for end-of-life care, such as resuscitation, organ donation, or power of attorney.
The nurse should assess the client’s readiness and understanding before initiating this conversation.
Choice D is wrong because it suggests that the client is close to death and needs hospice care, which can be discouraging and frightening. Hospice care is an interdisciplinary team effort that provides palliative care for clients who have a terminal illness and a life expectancy of less than 6 months.
The nurse should explain the benefits of hospice care and obtain the client’s consent before making a referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in a prone position can compromise respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Correct Answer is C
Explanation
Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss. Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.
Choice A is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.
Choice B is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.
Choice D is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.
Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults. Normal ranges for heart rate are 60 to 100 beats per minute for adults.
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