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The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.
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The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.
In the United States, several definitions of death are currently being used. The definition that uses apnea testing and pupillary responses to light is termed:
- A. whole brain death.
- B. heart-lung death.
- C. circulatory death.
- D. higher brain death.
Correct Answer: A
Rationale: The correct answer is 'whole brain death.' Most protocols for determining whole brain death require two separate clinical examinations, including the induction of painful stimuli, pupillary responses to light, oculovestibular testing, and apnea testing. This comprehensive approach ensures that all functions of the brain, including the brainstem, are evaluated to confirm the absence of brain function. Choices B and D are incorrect as they do not reflect the specific tests required for determining whole brain death. Choice C, 'circulatory death,' does not involve the evaluation of brain function and is not a current definition of death in the United States.
What is a common characteristic of individuals who become batterers?
- A. Grew up in a loving, secure home.
- B. Was an only child.
- C. Was physically or psychologically abused.
- D. Admits they have a problem with anger.
Correct Answer: C
Rationale: The correct answer is 'Was physically or psychologically abused.' Research indicates that many individuals who become batterers have a history of being abused themselves. This cycle of abuse can influence their behavior as adults. Choice A is incorrect because growing up in a loving home does not necessarily prevent someone from becoming a batterer. Choice B is incorrect as being an only child is not a determining factor in becoming a batterer. Choice D is incorrect because while admitting to anger issues is a positive step, it is not a common characteristic of individuals who become batterers.
A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.
- A. "You feel inadequate because you have never learned to balance a checkbook."?
- B. "You should have insisted your husband teach you about the finances."?
- C. "You are strong and will learn how to manage your finances after a while."?
- D. "I believe in your strength to learn how to manage your finances in time."?
Correct Answer: C
Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.
During the work phase of the nurse-client relationship, the client says to her primary nurse, "You think that I could walk if I wanted to, don't you?"? What is the best response by the nurse?
- A. "Yes, if you really wanted to, you could."?
- B. "Tell me why you're concerned about what I think."?
- C. "Do you think you could walk if you wanted to?"?
- D. "I think you're unable to walk now, whatever the cause."?
Correct Answer: D
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client's self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client's self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client's anxiety by suggesting unresolved psychological conflicts related to walking.