A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I feel worn out and don't have the energy to fight this disease. Am I dying?" Which of the following responses should the nurse make?

"Why do you think you are dying?"

"I think you should have some quiet time to get some rest."

"You are concerned that you are dying?"

"It is normal to feel this way with your type of cancer."

Answer and Explanation

The Correct Answer is C

A. "Why do you think you are dying?" This question can sound confrontational and may cause the client to feel defensive. It does not acknowledge the client’s feelings or encourage further communication about their concerns.

B. "I think you should have some quiet time to get some rest." While rest is important, this response dismisses the client’s emotional expression and does not address their fear or need for support regarding dying.

C. "You are concerned that you are dying?" This statement reflects the client’s feelings and encourages them to share more about their fears and concerns. It validates their emotions and opens a supportive dialogue.

D. "It is normal to feel this way with your type of cancer." Although normalizing feelings can be helpful, this response might minimize the client’s personal experience and does not directly explore their expressed worry about dying.

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Correct Answer is D

Explanation

A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.

B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.

C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.

D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.

A. Mark the length to be inserted on the tube with tape. B. Instruct the client to hyperextend her neck. C. Place a water-based lubricant on the tip of the tube. D. Compare the patency of the client's nares.

Correct Answer is D

Explanation

A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.

B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.

C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.

D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.

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A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I feel worn out and don't have the energy to fight this disease. Am I dying?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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