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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 rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.
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What are the implications for a client with renal insufficiency who wants to start a low-carbohydrate (CHO) diet?
- A. As long as the client eats a minimum of 30 g of CHO/day, there should be no problem.
- B. The client's clinical condition is a contraindication to starting a low CHO diet.
- C. Calcium supplements should be utilized to prevent the development of osteoporosis while on a low CHO diet.
- D. As long as the client eats foods that are high biologic protein sources, a low CHO diet can be followed.
Correct Answer: B
Rationale: A client with renal insufficiency should not start a low CHO diet because it could result in an increased renal solute load. Clients who have renal disease (renal failure, endstage renal disease [ESRD], dialysis, and transplant) or liver disease (liver failure, hepatic encephalopathy, cirrhosis, transplant, and hepatitis) require some form of protein control in dietary patterns to prevent complications from an inability to handle protein solute load. Proteins used in the diet must be of high biologic value, and protein intake is usually weight based, starting at 0.8 g/kg of dry weight, depending on the client's underlying clinical condition. Protein levels may be increased as necessary to account for metabolic response to dialysis and regeneration of liver tissue (1.5-2.0 g/kg/day). A minimum level of CHOs are needed in the diet (50-100 g/day) to spare protein. Vitamin and mineral supplements might be indicated with clients who have liver failure. The dietician is instrumental in calculating specific nutrient requirements for these clients and reviewing fluid intake and output, medication profile, and daily weight to monitor client outcomes in conjunction with dialysis technicians and nurses.
A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
- A. With a physical therapist treating the patient
- B. With a social worker planning for discharge
- C. With another nurse on duty to plan for break time
- D. In the hallway outside the patient's room.
Correct Answer: D
Rationale: Hallway discussions should not occur, because you do not know who is listening, even though it may be a professional discussion.
A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor?
- A. Adaptation Model
- B. Stimulus-Based Model
- C. Transaction-Based Model
- D. Selye's Model of Stress
Correct Answer: C
Rationale: The Transaction-Based Model is, according to R.S. Lazarus, a state that Stimulus theory and Response theory do not consider individual differences. He takes into account cognitive processes that intervene between the encounter and the reaction and the factors that affect the nature of this process. He includes mental and psychological components or responses as part of his concept of stress (Person-Environment Transactions).
A nurse observes a client sitting alone and talking. When asked, the client reports that he is 'talking to the voices.' The nurse's next action should be:
- A. touching the client to help him return to reality.
- B. leaving the client alone until reality returns.
- C. asking the client to describe what is happening.
- D. telling the client there are no voices.
Correct Answer: C
Rationale: Nurses might observe behavioral cues that can indicate the presence of hallucinations. Talking about the hallucinations is reassuring and validating to the client who has them. Focusing on the symptoms and asking about the hallucinations helps the client gain control.
A female having her first child is experiencing which type of crisis event?
- A. Situational
- B. Maturational
- C. Adventitious
- D. Reactive
Correct Answer: B
Rationale: Having a first child is a maturational crisis, requiring new coping strategies for the developmental transition to parenthood.