A nurse is caring for a client whose family just learned that he has terminal pancreatic cancer. The family requests the diagnosis be withheld from the client. Which of the following actions should the nurse take first?

Assist the client to make autonomous decisions about his treatment options.

Reflect on her own opinion about withholding the diagnosis from him.

Inform the family that he has a legal right to be informed of his diagnosis.

Determine the family's reasons for not telling him about his diagnosis.

Answer and Explanation

The Correct Answer is D

A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.

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Correct Answer is C

Explanation

A. "Self-examinations should be completed every 3 months." Self-examinations should be performed monthly, not every 3 months.
B. "I should squeeze the testicles firmly to determine the presence of lumps." Squeezing firmly can cause pain and is not necessary. The testicles should be examined gently.
C. "I should perform a self-examination after a warm shower." The warmth of the shower relaxes the scrotal skin, making it easier to feel any abnormalities.
D. "I should examine both of my testicles at the same time." Each testicle should be examined separately to ensure a thorough examination.

A. Install a bed exit sensor pad at the foot of the client's bed. B. Encourage the client to ambulate in compression stockings. C. Raise all four side rails for the client at bedtime. D. Place a raised toilet seat in the client's bathroom.

Correct Answer is D

Explanation

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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A nurse is caring for a client whose family just learned that he has terminal pancreatic cancer. The family requests the diagnosis be withheld from the client. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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