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A client with brain cancer is transferring to hospice care. The client's son tells the nurse, 'I don't know what to tell my dad if he asks how he is going to die.' Which of the following is an appropriate response by the nurse?
- A. "Let's talk more about your dad's condition."
- B. "The social worker will help you answer those questions."
- C. "I think that you should discuss this with the hospice nurse."
- D. "Try to help your dad enjoy this time as much as he can."
Correct Answer: D
Rationale: Choosing option D, 'Try to help your dad enjoy this time as much as he can,' is the most appropriate response by the nurse. This response shows empathy and compassion towards the client and their family during this difficult transition. The focus on supporting the client in enjoying their remaining time reflects a holistic approach to care. Options A, B, and C are not the best responses in this situation. Option A could lead to unnecessary details that might be overwhelming for the family. Option B shifts the responsibility to the social worker without providing immediate support. Option C deflects the son's concerns to another healthcare professional when emotional support is needed.
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A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?
- A. Apply the stockings with the creases on the front of the leg.
- B. Apply the stockings while the client's legs are in a dependent position.
- C. Remove the stockings at least once per shift.
- D. Remove the stockings while the client is sitting in a reclining chair.
Correct Answer: C
Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.
A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
- B. I will use crutches to support my weight on my left leg.
- C. When ascending stairs, I will lead with my left leg.
- D. I will keep my crutches under my arms for support.
Correct Answer: A
Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.
A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?
- A. "I should keep feeding my son whole milk until he is 3 years old."
- B. "It's okay for me to give my son a cup of apple juice with each meal."
- C. "I'll give my son about 2 tablespoons of each food at mealtimes."
- D. "My son loves popcorn, and I know it is better for him than sweets."
Correct Answer: C
Rationale: The correct answer is C. Offering a variety of foods in small portions is appropriate for a 2-year-old toddler as it helps provide balanced nutrition and allows the child to explore different tastes and textures. Choice A is incorrect because whole milk is recommended up to 2 years old, not until 3 years old. Choice B is incorrect as excessive juice intake can lead to excessive sugar consumption and is not recommended. Choice D is incorrect as popcorn may pose a choking hazard for toddlers and is not a suitable alternative to sweets.
The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's disease. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?
- A. Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care.
- B. Develop a chart for the client, listing the times the medication should be taken.
- C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.
- D. Instruct the client and client's children to put medications in a weekly pill organizer.
Correct Answer: C
Rationale: The priority nursing intervention in this scenario is to contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Simplifying the medication regimen is crucial for a client with early Alzheimer's disease to ensure they can manage their medications independently and safely. This intervention focuses on optimizing the client's ability to adhere to the prescribed medication schedule. Choices A and D involve external assistance and may not address the core issue of simplifying the regimen. Choice B, while helpful, does not directly address the need to simplify the regimen to enhance the client's medication management.
A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:
- A. Is not feeling well
- B. Reports severe pain
- C. Has low blood pressure
- D. Is anxious
Correct Answer: B
Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client's ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.