The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention?
- A. The client will ask all of his or her spiritual questions and get answers.
- B. The nurse is able to explain to the client how death will affect the spirit.
- C. Spirituality provides a sense of meaning and purpose for many clients.
- D. The nurse is the expert when assisting the client with spiritual matters.
Correct Answer: C
Rationale: Spirituality offers meaning and purpose, supporting holistic hospice care. Clients may not ask all questions, nurses aren’t spiritual experts, and death’s spiritual impact is subjective.
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Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse?
- A. The UAP is holding the phone to the ear of a client who is a quadriplegic.
- B. The UAP refuses to discuss the client's condition with the visitor in the room.
- C. The UAP put a vest restraint on an elderly client found wandering in the hall.
- D. The UAP is assisting the client with arthritis to open up personal mail.
Correct Answer: C
Rationale: Applying restraints without a physician’s order violates safety and legal standards, requiring intervention. Other actions are appropriate UAP tasks.
The hospice care nurse is planning the care of an elderly client diagnosed with end-stage renal disease. Which interventions should be included in the plan of care? Select all that apply.
- A. Discuss financial concerns.
- B. Assess any comorbid conditions.
- C. Monitor increased visual or auditory abilities.
- D. Note any spiritual distress.
- E. Encourage euphoria at the time of death.
Correct Answer: A,B,D
Rationale: Financial concerns, comorbidities, and spiritual distress are relevant for holistic hospice care in end-stage renal disease. Visual/auditory increases or euphoria are not typical interventions.
The nurse is admitting a client to the medical surgical unit. Which is required to be offered to the client if the hospital accepts Medicare reimbursement?
- A. The opportunity to make an advance directive.
- B. The client must be referred to a case manager.
- C. The client must apply for a Medicare supplement insurance.
- D. The opportunity to discuss end-of-life issues.
Correct Answer: A
Rationale: The Patient Self-Determination Act mandates offering ADs on admission for Medicare-funded hospitals. Case management, insurance, or end-of-life discussions are not required.
Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior?
- A. The Hippocratic Oath.
- B. The Nuremberg Code.
- C. Home Health Care Bill of Rights.
- D. ANA Code of Ethics.
Correct Answer: D
Rationale: The ANA Code of Ethics guides nurses on ethical behavior and decision-making, specific to nursing practice. Other documents are less relevant or outdated.
Which interventions should the nurse implement at the time of a client's death? Select all that apply.
- A. Allow gaps in the conversation at the client's bedside.
- B. Avoid giving the family advice about how to grieve.
- C. Tell the family the nurse understands their feelings.
- D. Explain this is God's will to prevent further suffering.
- E. Allow the family time with the body in private.
Correct Answer: A,B,E
Rationale: Allowing silence, avoiding prescriptive grief advice, and providing private time support family grieving. Claiming understanding or invoking God’s will may alienate or presume.