A nurse is developing a care plan for Mrs. Thompson who is in the end-of-life stage. After assessing the client, the nurse has identified several potential problems. Which of the following hypotheses should the nurse prioritize when planning care for this client?

The client may benefit from additional laboratory tests to monitor disease progression.

The client may experience pain and discomfort due to the progression of their illness.

The client may need increased physical therapy sessions to maintain mobility.

The client may have elevated blood pressure due to an acute exacerbation of their condition.

Answer and Explanation

The Correct Answer is B

A. Additional laboratory tests: While monitoring is essential, at this stage, the priority is comfort, not disease progression.

B. Pain and discomfort: Mrs. Thompson is nearing the end of life and likely experiencing pain due to her advanced metastatic cancer. Pain management should always be a priority in palliative care.

C. Physical therapy: Physical therapy is not typically a priority in the end-of-life stage where the focus is on comfort rather than mobility.

D. Elevated blood pressure: This is unlikely to be the primary concern at this stage. Blood pressure is usually low, and interventions should be focused on comfort and symptom relief.

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Correct Answer is D

Explanation

A. "I promise I won't tell anyone about this." This is incorrect because nurses are mandated reporters and must report abuse to appropriate authorities. Promising confidentiality is misleading and violates legal obligations.

B. "Your family is bad for doing this to you." Making judgmental statements about the family can hinder the therapeutic relationship and may increase the child’s stress or feelings of loyalty conflict.

C. "Let's discuss what happened with your family here." Discussing abuse in the presence of the family may put the child at risk for retaliation and discourage open communication.

D. "It is not your fault that this happened." This statement reassures the child and helps mitigate feelings of guilt or shame that are common in abuse victims. It is supportive, nonjudgmental, and developmentally appropriate, fostering trust and safety.

A. Observe the patient's facial expressions and body language for signs of discomfort. B. Measure the patient's vital signs and note any changes. C. Review the patient's medical history for past pain management interventions and their outcomes. D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity.

Correct Answer is D

Explanation

A. Observe the patient's facial expressions and body language for signs of discomfort: While observation is important, it doesn't provide a complete picture of the client's pain experience and may not capture all aspects, such as intensity or location.

B. Measure the patient's vital signs and note any changes: Vital signs are important but can be nonspecific indicators of pain and are not as reliable for assessing pain intensity or quality.

C. Review the patient's medical history for past pain management interventions and their outcomes: While this is useful, it does not directly address the client's current pain experience.

D. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity. A comprehensive pain assessment requires the client's self-report to fully understand the pain's characteristics. A pain scale (e.g., 0-10) helps quantify the intensity, and asking about its location, duration, and type allows for a thorough understanding of the pain's impact.

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A nurse is developing a care plan for Mrs. Thompson who is in the end-of-life stage. After assessing the client, the nurse has identified several potential problems. Which of the following hypotheses should the nurse prioritize when planning care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?

Correct Answer is D

Explanation

A nurse is conducting a pain assessment for a client who reports discomfort. Which of the following actions is the most appropriate for the nurse to take to obtain a comprehensive understanding of the client's pain?

Correct Answer is D

Explanation

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A nurse is developing a care plan for Mrs. Thompson who is in the end-of-life stage. After assessing the client, the nurse has identified several potential problems. Which of the following hypotheses should the nurse prioritize when planning care for this client?

A nurse is educating a client about their responsibilities in managing their chronic condition. Which of the following statements by the client demonstrates an understanding of their healthcare responsibilities?