Nokea
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?
- A. Ask the wife how she would like to participate in the client's care.
- B. Provide the wife with information about hospice.
- C. Encourage the wife to visit during and after painful treatments are completed.
- D. Refer the wife to a support group for family members of those dying of cancer.
Correct Answer: A
Rationale: During this difficult time of coping with terminal cancer diagnosis, involving the wife in the care process can help her feel more in control and connected. This can be beneficial for both the client and his wife, as it fosters a collaborative approach to care and ensures the wife's needs and preferences are considered.
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The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?
- A. To promote oxygenation by removing secretions.
- B. To reduce the amount of air trapped in the lungs.
- C. To increase the amount of carbon dioxide exhaled.
- D. To slow the respiratory rate and improve air exchange.
Correct Answer: C
Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A), reducing air trapping (B), and slowing the respiratory rate (D) can be associated benefits, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics.
During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement in the client's spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client's choice
Correct Answer: B
Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
- A. The client's respiratory rate is 14 breaths per minute.
- B. The client's oxygen saturation is 92%.
- C. The client reports shortness of breath.
- D. The client's respiratory rate is 24 breaths per minute.
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.
During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?
- A. Temperature increases from 98.8° to 99.0° F.
- B. Pulse rate decreases from 78 to 52 beats/min.
- C. Respiratory rate increases from 16 to 24 breaths/min.
- D. Blood pressure increases from 110/84 to 118/88 mmHg.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.