The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Maintain a cheerful and calm appearance while spending time with the client.

Listen for changes in what the client hopes for and try to help meet the goals.

Avoid the client having to make any decisions to help save the client's energy.

Offer meals prepared with the client's favorite foods at frequent, regular intervals.

Answer and Explanation

The Correct Answer is B

A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.
B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.
C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.
D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.

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Correct Answer is D

Explanation

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

A. Elevate the head of the bed to at least 45 degrees. B. Use at least two different methods to identify the client. C. Provide a fresh glass of water for taking the medications. D. Recheck the prepared medications against the medication administration record (MAR).

Correct Answer is B

Explanation

A. Elevating the head of the bed is important for swallowing and preventing aspiration but is secondary to ensuring correct patient identification.
B. Using at least two different methods to identify the client is the most important step to prevent medication errors. This ensures that the correct medication is given to the correct patient.
C. Providing water is helpful but not as critical as ensuring the correct patient is identified.
D. Rechecking the medications against the MAR is important but should be done in conjunction with proper patient identification.

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The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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