The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Request a spiritual advisor's consult.

Encourage viewing of the body to accept the death.

Provide support of the spouse's feelings.

Ask the relatives about how the spouse is coping.

Answer and Explanation

The Correct Answer is C

A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.

B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.

C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.

D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.

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Free Nursing Study Resources

Correct Answer is ["C","D","E","F","H"]

Explanation

A. Perform aggressive weight bearing exercises: Aggressive weight-bearing exercises may place too much strain on the joints, especially for someone with RA. Low-impact activities, such as swimming or walking, are generally recommended to avoid exacerbating joint damage or pain.

B. Anticipate dry eyes and mouth; no intervention is needed: While dry eyes and mouth can occur in autoimmune diseases like RA, particularly if the client has secondary Sjögren's syndrome, they should not be ignored. The nurse should advise the client to seek treatment for these symptoms, as interventions can provide relief.

C. Take hot showers to help relieve stiffness: Warm showers or baths can help reduce the stiffness and pain associated with rheumatoid arthritis (RA) by relaxing muscles and improving circulation. This can be an effective method to manage the morning stiffness that the client experiences.

D. Observe skin for any lesions: Skin lesions can be a result of certain medications or the disease process itself. RA treatment, particularly with medications like methotrexate or biologics, can increase the risk of skin issues, and regular monitoring is important for early identification.

E. Watch for gastrointestinal upset with medication administration: NSAIDs like ibuprofen, which the client is taking for pain, can cause gastrointestinal issues such as ulcers or irritation. Monitoring for these symptoms is important to avoid complications related to the medication.

F. Discuss body image feelings with a trusted friend or therapist: The chronic nature of RA, along with potential joint deformities and limitations, can impact body image. Discussing these feelings with a trusted person or therapist can help the client manage the psychological aspects of living with a chronic condition.

G. Avoid fluids, to decrease trips to the bathroom: Reducing fluid intake could lead to dehydration, which may cause other complications. The client should be encouraged to drink adequate fluids, despite more frequent trips to the bathroom, to stay properly hydrated.

H. Prioritize rest, with short periods of activity: RA can cause joint fatigue and pain. It’s important to balance periods of rest with light, non-strenuous activities to reduce stress on the joints while maintaining some level of mobility. This can help manage energy levels and minimize joint strain.

A. Ask the client if she has any alcohol in the room at this time. B. Administer an PRN prescription for an antianxiety drug. C. Inform the family that they are enabling the client. D. Observe for signs to determine if client is inebriated. E. Schedule a conference with the client and family members.

Correct Answer is ["A","D","E"]

Explanation

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.

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The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.

Correct Answer is ["C","D","E","F","H"]

Explanation

Correct Answer is ["A","D","E"]

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

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Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

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The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?