A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Contact the facility chaplain to visit with the client.
Explain the process of leaving the facility against medical advice.
Make a referral for social services.
Encourage the client to continue with inpatient care.
The Correct Answer is C
- A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.
- B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.
- C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.
- D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.
- B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.
- C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.
- D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.
Correct Answer is ["A","C","E"]
Explanation
Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.
The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.
Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.
The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.
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