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
The correct answer is choice A. “Would you like to speak to a spiritual advisor?”.
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 D
Explanation
Choice A reason
Abdomen area is not appropriate: Assessing skin turgor on the abdomen is not commonly performed. The abdomen may not be the most accurate site for assessing skin turgor, especially in older adults, as it can be influenced by factors such as body fat distribution.
Choice B reason:
Shoulder are is not appropriate: The shoulder is not a typical site for assessing skin turgor. It is generally not used for this purpose, as it may not provide reliable results
Choice C reason:
Stomach is not the correct answer.: Assessing skin turgor on the stomach is also not commonly performed. The abdomen or stomach may not be the most accurate site for assessing skin turgor, especially in older adults.
Choice D reason
When assessing skin turgor in an older adult client, the nurse should lift the skin on the neck to evaluate its elasticity and hydration status. Skin turgor is a measure of skin's elasticity and is commonly used as an indicator of hydration in both adults and older adults.
To assess skin turgor, the nurse will gently pinch a small amount of skin on the back of the client's hand or the front of the chest (sternum). However, since the options listed do not include these areas, the closest alternative for an older adult would be the neck.
Correct Answer is D
Explanation
I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery.
Elevation promotes venous return and prevents fluid accumulation in the tissues.
Choice A is wrong because applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.
Choice B is wrong because the client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.
Choice C is wrong because numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.
The client should expect these symptoms to improve or resolve after surgery, not persist or worsen. If the client experiences numbness and tingling after surgery, they should report it to the surgeon as it may indicate a complication such as nerve injury or hematoma.
Normal ranges for grip strength, pinch strength, and keypinch strength vary depending on age, sex, and hand dominance. However, a general reference for grip strength is 20 to 40 kg for men and 15 to 30 kg for women. For pinch strength, it is 6 to 12 kg for men and 5 to 10 kg for women. For keypinch strength, it is 4 to 8 kg for men and 3 to 7 kg for women.
These values may be lower in older adults or people with chronic conditions.
The client should expect some loss of strength in the affected hand after surgery, but it should gradually improve with rehabilitation.
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