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Which statement is true regarding the impact of culture on end-of-life decision making?
- A. African-Americans prefer more conservative, less invaasbiirvbe.c ocma/rtees to ptions during the end of life.
- B. Caucasians prefer aggressive and more invasive care options during the end of life.
- C. Culture and religious beliefs may affect end-of-life decision making.
- D. Perspectives regarding end-of-life care are similar betwabeirebn.c oamn/dte swt ithin religious groups.
Correct Answer: C
Rationale: Rationale:
1. Culture and religious beliefs can significantly impact end-of-life decision making by influencing values, beliefs, and preferences.
2. These factors may affect choices related to treatment options, quality of life, and spiritual aspects.
3. Different cultural backgrounds may lead to varying perspectives on autonomy, family involvement, and medical interventions.
4. Option A and B make generalizations based on race, which is not accurate as preferences can vary widely within any racial group.
5. Option D is incorrect as perspectives on end-of-life care can vary even within the same religious group due to individual beliefs and interpretations.
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The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
- A. She is senile.
- B. She is in the exhaustion stage of the general adaptation syndrome to stress.
- C. She is assuming the role of caregiver in place of the patient, a role she is not used to.
- D. She has macular degeneration and cannot see well.
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress.
Rationale:
1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope.
2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition.
3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion.
4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse.
Summary:
A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation.
C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion.
D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
- A. Agitation
- B. Apathy
- C. Biting
- D. Hitting
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?
- A. Cardiorespiratory.
- B. Liver.
- C. Sensory.
- D. Kidney.
Correct Answer: B
Rationale: The correct answer is B: Liver. The nurse should monitor liver function in this client because acetaminophen is primarily metabolized in the liver. Alcohol abuse can also contribute to liver damage, increasing the risk of liver toxicity from acetaminophen. Monitoring liver function tests like AST, ALT, and bilirubin levels can help detect any liver damage early.
Choice A, cardiorespiratory, is not directly related to acetaminophen or alcohol abuse in this scenario. Choice C, sensory, is not relevant to monitoring organ function in this context. Choice D, kidney, is not the primary concern because acetaminophen is mainly metabolized in the liver, and kidney function is not typically affected by acetaminophen use.
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.