The nurse is caring for a child who has a diagnosis of metastatic brain cancer. The father states "I can't believe this is happening to us, I feel numb." Which of the following nursing interventions by the nurse is the first priority?

Instruct the family about anticipatory grieving

Explore effective ways of family coping

Encourage the family’s expression of their feelings

Discuss the disease and its manifestations with family members

Answer and Explanation

The Correct Answer is C

A. Instruct the family about anticipatory grieving: While anticipatory grieving is important, it is better addressed after the family has had time to express initial feelings.

B. Explore effective ways of family coping: This is important but should come after encouraging the family to process their immediate feelings.

C. Encourage the family’s expression of their feelings. The first priority is to allow the family to express their emotions and begin the grieving process. Encouraging emotional expression helps the family cope with the overwhelming news and facilitates their emotional support needs.

D. Discuss the disease and its manifestations with family members: While understanding the disease is essential, focusing on the family's emotional response is more critical at this initial stage of shock and grief.

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Correct Answer is C

Explanation

A. Encouraging client feedback about satisfaction with the facility experience: This reflects client-centered care but does not directly demonstrate autonomy.

B. Explaining unit rules and policies regarding unacceptable behaviors: This action involves setting expectations rather than promoting client autonomy.

C. Supporting the client's wish to refuse prescribed medications. Autonomy involves respecting a client's right to make their own decisions about their care, including the decision to refuse treatment, as long as they have the capacity to do so.

D. Making sure the client understands expectations for client participation: This is about ensuring clarity of expectations rather than honoring the client's right to self-determination.

A. Respiratory rate 8/min B. SaO2 94% C. Pain level of 6 on a scale from 0 to 10 D. Sleepy, but arousing when her name is called

Correct Answer is A

Explanation

A. Respiratory rate 8/min: Morphine sulfate is an opioid that can depress respiratory function. A respiratory rate of 8/min is dangerously low and indicates opioid-induced respiratory depression, a serious adverse effect that requires immediate intervention.

B. SaO2 94%: A SaO2 of 94% is within the normal range for many clients and does not indicate an immediate issue.

C. Pain level of 6 on a scale from 0 to 10: This is an expected finding after morphine administration, as it typically reduces pain but may not eliminate it entirely.

D. Sleepy, but arousing when her name is called: Sedation is a common side effect of morphine, but the client being arousable when their name is called is not an alarming sign.

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The nurse is caring for a child who has a diagnosis of metastatic brain cancer. The father states "I can't believe this is happening to us, I feel numb." Which of the following nursing interventions by the nurse is the first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Correct Answer is A

Explanation

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