Nokea
A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic.
Which of the following nursing goals should be a priority at this time?
- A. Encourage client to talk about the possibility of dying.
- B. Provide pain assessment and effective pain management.
- C. Manage nutrition and hydration.
- D. Verify that the physician has discussed the prognosis with the family.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct-comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important, but will be difficult if client's pain is not adequately controlled (4) not highest priority
You may also like to solve these questions
A client had a thoracotomy 3 hours ago. For the past 2 hours there has been 100 cc per hour of bloody chest drainage. Which of the following actions should the nurse take FIRST?
- A. Increase the IV fluid rate.
- B. Administer oxygen at 5 L/min per oxygen mask.
- C. Elevate the head of the bed.
- D. Advise the physician of the amount of drainage.
Correct Answer: D
Rationale: Excessive chest drainage (100 cc/hour) suggests hemorrhage, requiring immediate physician notification. Options A, B, and C are secondary interventions.
A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.
The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
A 28-year-old client is admitted to the hospital unit with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following?
- A. Protective isolation.
- B. Airborne precautions.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: C
Rationale: standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.