Nokea
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
- A. The delay of the impending death
- B. Offering a caring support system
- C. Providing measure focused on pain management
- D. Introduction of interventions that enhance the quality of life
- E. Expanding the focus of care to both the client and the family
- F. Addressing the expressed spiritual needs of the client and the family
Correct Answer: B,C,D,E,F
Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: offering a support system to help the client live as actively as possible until death; providing relief from pain and other distressing symptoms; enhancing the quality of life; offering a support system to help families cope during the client's illness and their own bereavement; affirming life and regarding dying as a normal process, neither hastening nor postponing death; and integrating psychological and spiritual aspects of client care.
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The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
- A. Perform frequent biophysical profiles.
- B. Monitor for elevated serum creatinine.
- C. Monitor for manifestations of infection.
- D. Teach the client how to count fetal movements.
- E. Use strict sterile technique for vaginal examinations.
- F. Inform the client about the need for tocolytic therapy.
Correct Answer: A,C,D,E
Rationale: Premature rupture of membranes (PROM) increases the risk of infection, preterm labor, and fetal compromise. Frequent biophysical profiles assess fetal well-being. Monitoring for manifestations of infection is critical due to the risk of chorioamnionitis. Teaching the client to count fetal movements helps monitor fetal activity and detect potential distress. Strict sterile technique for vaginal examinations minimizes infection risk. Monitoring serum creatinine is not directly related to PROM management. Tocolytic therapy may be considered but is not universally required unless preterm labor is confirmed.
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
- A. Assist the client to develop a daily bowel routine to prevent constipation.
- B. Teach the client to manage emotional stressors by using mental imaging.
- C. Assess vital signs and observe for hypotension, tachycardia, and tachypnea.
- D. Administer dexamethasone orally per the primary health care provider's prescription.
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. Options 3 and 4 are unrelated to this specific condition. A client with autonomic hyperreflexia would be severely hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and symptoms.
A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure?
- A. Ambulate the client.
- B. Clamp the chest tube.
- C. Ask the client to cough and deep breathe.
- D. Ask the client to remain in a side-lying position.
Correct Answer: B
Rationale: After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.