Nokea
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response begins following a terminal diagnosis
- B. A client whose grief response is repressed
- C. A client whose grief response is triggered by a secondary loss
- D. A client whose grief response leads to self-destructive behaviors
Correct Answer: D
Rationale: Exaggerated grief involves extreme, self-destructive reactions beyond normal grieving.
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A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Aren't you interested in learning how to perform this test?
- B. Let's talk about what you're thinking.
- C. I'll discuss this with your partner instead.
- D. Is this something you think you can do?
Correct Answer: B
Rationale: Exploring the client's thoughts addresses distractions and improves teaching effectiveness.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink an average of 2,000 milliliters of water daily.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink two hot cups of coffee each morning.
Correct Answer: B
Rationale: Opioids can cause constipation, impairing bowel elimination.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Prepare the client for surgery with implied consent.
- D. Request that the provider sign the consent form.
Correct Answer: C
Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.