The hospice nurse assesses a client newly admitted to hospice care.
Which is the nurse's priority assessment?
Assess the client's medical diagnosis.
Assess the client's financial situation.
Assess the client's spiritual needs.
Assess the client's support system.
The Correct Answer is A
Determining priority assessments in hospice care requires applying Maslow's hierarchy and the nursing process. Understanding the medical diagnosis is foundational for anticipating physical needs, managing symptoms, and ensuring safety, which precedes addressing psychosocial, spiritual, or financial concerns during the initial admission phase.
Choice A rationale
Identifying the medical diagnosis is essential for clinical decision making and symptom management. It allows the nurse to anticipate complications, understand prognosis, and provide appropriate pharmacological interventions to ensure comfort, which is the primary goal of hospice.
Choice B rationale
While financial stability affects long term care planning, it is not the immediate clinical priority upon admission. Basic physiological needs and medical stability must be addressed before the nurse evaluates the client's insurance coverage or socioeconomic status.
Choice C rationale
Spiritual assessment is a core component of holistic hospice care, yet it follows physical stabilization. The nurse must first ensure the client is not in acute physical distress before exploring religious beliefs or existential concerns.
Choice D rationale
Assessing the support system is vital for planning home care and caregiver respite. However, without understanding the medical condition first, the nurse cannot accurately determine the level of support or specific skills the family needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Disseminated intravascular coagulation involves systemic activation of coagulation, leading to microthrombi formation. Assessing for organ dysfunction requires understanding how thrombotic microangiopathy causes ischemia in high-vascularity organs, specifically focusing on renal and hepatic biomarkers and physiological changes in perfusion.
Choice A rationale
Thrombotic microangiopathy in the lungs would typically cause increased respiratory rates and decreased oxygen saturation due to impaired gas exchange. Decreased rates and normal saturation do not indicate the ischemic damage associated with microvascular clotting.
Choice B rationale
The kidneys are highly susceptible to microthrombi. Elevated BUN (normal 10 to 20 mg/dL) and creatinine (normal 0.6 to 1.2 mg/dL) indicate acute kidney injury caused by fibrin deposition and subsequent ischemia in the glomerular capillaries.
Choice C rationale
While bilirubin might rise due to hemolysis, white blood cell counts are not a primary indicator of thrombotic organ dysfunction. Bilirubin increases are more common in hepatic failure or red blood cell fragmentation during DIC.
Choice D rationale
DIC typically presents with abnormal coagulation profiles, including prolonged PT and PTT and low fibrinogen. Normal profiles would contradict the diagnosis of DIC, even if transaminases were elevated due to localized hepatic microvascular occlusion.
Correct Answer is ["10"]
Explanation
Step 1 is 1 mg ÷ (0.1 mg ÷ 1 mL).
Step 2 is 1 mg ÷ 0.1 mg/mL = 10 mL. Final answer is 10 mL..
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