Nokea
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important as it allows the family to have closure, grieve, and say their goodbyes in a respectful and private manner. It also promotes a sense of dignity and respect for the deceased. Choice A is incorrect as it may delay the family's grieving process. Choice B is incorrect as postmortem care should be performed after the family has had a chance to view the body. Choice C may be helpful but is not as essential as allowing the family to view the body privately.
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The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important to facilitate the grieving process and provide closure. Allowing the family to view the body privately enables them to say goodbye in their own way and can help them come to terms with the loss. It shows respect for the family's cultural and religious beliefs regarding death and mourning. It also allows for a more personal and intimate experience for the family members.
Choice A is incorrect because asking the family to return after the staff cleans the body may cause unnecessary delays and distress for the family. Choice B is incorrect as performing postmortem care should not take precedence over allowing the family to view the body. Choice C, having a clergy member present, is a supportive gesture but does not address the immediate needs of the family to see the deceased.
A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This is the most appropriate intervention as older adults with dementia may have difficulty expressing their needs and may forget to use the bathroom. Establishing a routine for bathroom breaks can prevent accidents and promote comfort. Choice A is incorrect as isolating the client may increase agitation. Choice B is incorrect as using all four side rails can be a safety hazard and restrict mobility. Choice C is incorrect as it does not address the specific issue of wandering at night.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
A client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
- A. Diaphoresis
- B. Retractions
- C. Cyanosis
- D. Restlessness
Correct Answer: D
Rationale: Restlessness is an early sign of inadequate oxygenation, indicating the body's attempt to compensate for low oxygen levels.