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The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
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The nurse is caring for an adult being admitted with a head injury. The nurse plans to place the client in which position?
- A. Prone
- B. Supine
- C. Semi-reclining
- D. Upright
Correct Answer: C
Rationale: Semi-reclining (30-45 degrees) reduces intracranial pressure in head injury by promoting venous drainage, unlike prone, supine, or upright positions.
The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.
- A. I need to avoid taking medicines like ibuprofen without a prescription.
- B. I should avoid drinking excess coffee or cola.
- C. I should enroll in a smoking cessation program.
- D. I should reduce or eliminate my intake of alcoholic beverages.
- E. I will eliminate whole wheat foods, like breads and cereals, from my diet.
Correct Answer: A,B,C,D
Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.
Because a client has Addison's disease, the nurse would expect to see which of the following in the nursing assessment?
- A. A supraclavicular fat pad
- B. A puffy face
- C. Low blood pressure
- D. Ecchymotic areas
Correct Answer: C
Rationale: Addison's disease causes cortisol and aldosterone deficiency, leading to hypotension. Fat pads and puffy face are Cushing's symptoms, and ecchymosis is less specific.
Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:
- A. Asian
- B. African-American
- C. Latino
- D. Native American
Correct Answer: D
Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.