An adult male was diagnosed with stage IV lung cancer three weeks ago.
His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.
Which is the best response by the nurse?
Gather information regarding how long it will take for the children to arrive.
Explain that the client will start to lose consciousness and the body systems will slow down.
Offer to discuss the client's health status with each of the adult children.
Reassure the spouse that the healthcare provider will notify when to call the children.
The Correct Answer is B
Choice B rationale:
Explaining that the client will start to lose consciousness and the body systems will slow down is the best response. This is a common pattern in the dying process, and it provides the wife with a clear and compassionate explanation of what to expect as her husband's death approaches.
Choice A rationale:
Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.
Choice C rationale:
Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.
Choice D rationale:
Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.
Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.
Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.
Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.
Correct Answer is D
Explanation
Choice A rationale:
Aspirin is not typically contraindicated in a client who has taken sildenafil unless there are specific contraindications or allergies. Aspirin is often used in the management of acute chest pain to help prevent blood clot formation.
Choice B rationale:
Heparin is not contraindicated solely because the client has taken sildenafil. Heparin is an anticoagulant commonly used in various clinical settings, including the management of certain cardiac conditions.
Choice C rationale:
Morphine is not necessarily contraindicated based solely on the client's use of sildenafil. Morphine can be used to relieve chest pain in some cases of acute coronary syndrome. However, its use should be carefully evaluated based on the client's overall clinical presentation.
Choice D rationale:
Nitroglycerin should be withheld in this scenario. Sildenafil is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. It can potentiate the vasodilatory effects of nitroglycerin, leading to a severe drop in blood pressure. Concomitant use of nitroglycerin and sildenafil is contraindicated due to the risk of significant hypotension, which can be life-threatening.
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