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The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?
- A. Have the client see a psychologist because the pain is not real.
- B. Tell the client the pain is the cancer coming back.
- C. Refer the client to a physical therapist to prevent a frozen shoulder.
- D. Discuss changing the client to a more potent narcotic medication.
Correct Answer: C
Rationale: PMP can lead to shoulder immobility; physical therapy prevents frozen shoulder, per evidence-based practice. Psychological dismissal, cancer assumptions, or narcotics are inappropriate.
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The client is dying and wants to talk to the nurse about heaven. Which is the nurse's best nursing action?
- A. Make a referral to the chaplain to come to see the client.
- B. Tell the client that nurses are not allowed to discuss spiritual matters.
- C. Ask the client to describe heaven and hell.
- D. Allow the client to discuss the beliefs about heaven.
Correct Answer: D
Rationale: Allowing discussion of heaven respects client spirituality, per holistic care. Chaplain referral, prohibiting discussion, or prompting hell discussion is less supportive.
The 38-year-old client was brought to the emergency department with CPR in progress and expired 15 minutes after arrival. Which intervention should the nurse implement for postmortem care?
- A. Do not allow significant others to see the body.
- B. Do not remove any tubes from the body.
- C. Prepare the body for the funeral home.
- D. Send the client's clothing to the hospital laundry.
Correct Answer: C
Rationale: Preparing the body (e.g., cleaning, positioning) respects dignity and funeral home needs. Denying family access, leaving tubes, or laundering clothes is inappropriate.
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process?
- A. How angry are the family members about the death?
- B. Which family member will be making decisions?
- C. What previous coping skills have been used?
- D. What type of funeral service has been planned?
Correct Answer: C
Rationale: Previous coping skills inform tailored grief interventions, per nursing process. Anger, decision-makers, or funeral plans are less critical initially.
The wife of a client receiving hospice care being cared for at home calls the nurse to report the client is restless and agitated. Which interventions should the nurse implement? List in order of priority.
- A. Request an order from the health-care provider for antianxiety medications.
- B. Call the medical equipment company and request oxygen for the client.
- C. Go to the home and assess the client and address the wife's concerns.
- D. Reassure and calm the wife over the telephone.
- E. Notify the chaplain about the client's change in status.
Correct Answer: C,D,A,B,E
Rationale: 1) Assess client at home (determine cause of agitation); 2) Reassure wife (immediate support); 3) Request antianxiety medication (if indicated); 4) Request oxygen (if hypoxia present); 5) Notify chaplain (spiritual support).