A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?

"I think you should call your friends to comfort you."

"Things are not as bad as they seem right now."

"It must be a very difficult time for you."

"Why are you afraid that you are going to die?"

Answer and Explanation

The Correct Answer is C

A. "I think you should call your friends to comfort you.": This deflects the client’s feelings and shifts responsibility to others, rather than addressing the client’s immediate emotional needs.

B. "Things are not as bad as they seem right now.": This minimizes the client’s fear and invalidates their feelings, which can prevent open communication about their concerns.

C. "It must be a very difficult time for you.": This is a therapeutic, empathetic response that acknowledges the client’s emotions and encourages them to share their fears in a supportive manner.

D. "Why are you afraid that you are going to die?": Asking "why" can sound judgmental or probing, which may make the client defensive instead of fostering trust and open discussion.

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Correct Answer is A

Explanation

A. 30° lateral: The 30-degree lateral position is recommended to reduce pressure on bony prominences such as the trochanters, sacrum, and heels. It distributes weight more evenly and decreases the risk of pressure injury compared to lying directly on the side or back.

B. Lateral semi-prone recumbent: This position places significant pressure on the greater trochanter and shoulder, which increases the risk of skin breakdown. It is not the safest choice for clients at high risk of pressure injuries.

C. Supine: Lying flat on the back concentrates pressure on the sacrum, heels, and occiput. Prolonged supine positioning without frequent repositioning contributes to rapid development of pressure injuries.

D. 45° supported Fowler's: While Fowler’s position can help with breathing, it increases pressure on the sacrum and ischial tuberosities. Extended use in this position places immobile clients at a greater risk for pressure injuries.

A. Strong, bounding pulse B. Positive Chvostek's sign C. Hyperactive reflexes D. Decreased bowel sounds

Correct Answer is D

Explanation

A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.

B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.

C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.

D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.

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A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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