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While assessing a client who is dying for signs of impending death, what should the nurse observe for?
- A. Elevated blood pressure
- B. Cheyne-Stokes respiration
- C. Elevated pulse rate
- D. Decreased temperature
Correct Answer: B
Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.
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Which task should not be performed by the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Initiating a blood transfusion
Correct Answer: D
Rationale: A licensed practical nurse should not initiate a blood transfusion. LPNs can assist with transfusions and verify ID numbers but should not be assigned to initiate the procedure. Inserting Foley catheters, discontinuing nasogastric tubes, and obtaining sputum specimens are within the scope of practice for LPNs. Therefore, options A, B, and C are tasks that LPNs can perform, making them incorrect choices.
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choice A is incorrect because knowledge of the frequency of elder abuse is not a significant factor in a victim's reluctance to report. Choice B is also incorrect; while some victims may have feelings of undeservedness, it is not a common primary barrier to reporting abuse. Choice C is incorrect as the lack of appropriate screening tools may hinder identification but is not a significant barrier for the client to admit being a victim. Therefore, the correct answer is D, as the fear of reprisal or further violence if the incident is reported is a common and significant barrier for elderly clients to admit being a victim.
To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?
- A. Tell the client to stop using the defense mechanism of denial
- B. Positively reinforce each expression of feelings
- C. Instruct the client to express feelings
- D. Challenge the client each time denial is used
Correct Answer: B
Rationale: The most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.
How does the ANA define the psychiatric nursing role?
- A. a specialized area of nursing practice that employs theories of human behavior as its science and the powerful use of self as its art
- B. assisting the therapist to relieve the symptoms of clients
- C. to solve clients' problems and give them the answers
- D. having a client committed to long-term therapy with the nurse
Correct Answer: A
Rationale: The correct answer aligns with the ANA's definition of the psychiatric nursing role. According to the ANA, psychiatric nursing is a specialized area of nursing practice that incorporates theories of human behavior as its foundational science and utilizes the self as its essential art. This definition emphasizes the importance of understanding human behavior and leveraging therapeutic communication and relationships to provide effective care for individuals with mental health concerns. Choices B, C, and D are incorrect because they do not accurately represent the ANA-defined role of psychiatric nursing. Psychiatric nurses primarily focus on delivering holistic care, promoting mental health, and supporting individuals with mental health challenges using evidence-based practices and therapeutic interventions.
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That can be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: The correct answer is B: 'That is in situ.' Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and metastasis. Answer A is incorrect because Tis indicates a tumor that is in situ and can be assessed. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.