A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?
Be honest with the client about the prognosis.
Allow the client to choose treatment times.
Provide privacy during client care procedures.
Administer pain medication on a routine schedule.
The Correct Answer is B
Giving the client the opportunity to participate in decision-making regarding the timing of treatments and procedures respects their autonomy and allows them to have some control over their care.
Be honest with the client about the prognosis: By providing accurate and honest information, the nurse respects the client's right to know and be involved in decision-making regarding their healthcare.
Provide privacy during client care procedures: Respecting the client's privacy during care procedures allows them to maintain a sense of dignity and control over their body.
Administer pain medication on a routine schedule: Ensuring that pain medication is provided on a routine schedule allows the client to have control over their pain management and helps maintain their comfort and quality of life
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.
B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.
C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.
D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.
Correct Answer is B
Explanation
A.Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B.Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C.Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
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