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You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients?
- A. The client will accept impending death
- B. Guilt related to past transgressions
- C. Spiritual distress related to guilt
- D. Pain related to end of life symptoms
Correct Answer: A
Rationale: Accepting impending death is a common and appropriate goal for hospice clients, as it aligns with the focus of palliative care on achieving peace and closure at the end of life.
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A client with a history of heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypokalemia.
- C. Hypernatremia.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, can cause hypokalemia by increasing potassium excretion in the urine.
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
- A. What happened between you and your child?'
- B. Why is your child screaming?'
- C. Did something cause your child to be upset?'
- D. Have you tried to calm down your child?'
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
A mother is concerned about the amount of snacking her teenage boy is doing. She is concerned that this behavior could lead to obesity. Which of the following is an appropriate percentage of the daily diet to be obtained from snacks?
- A. 10%.
- B. 25%.
- C. 40%.
- D. 50%.
Correct Answer: B
Rationale: Snacks should contribute about 25% of daily caloric intake to balance nutrition without leading to excessive weight gain.
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
- A. Administer an antacid.
- B. Notify the physician.
- C. Offer a light snack.
- D. Assess the pain characteristics.
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?
- A. Close the day care center for 1 week to control the outbreak.
- B. Restrict the infected children from returning for 48 hours after treatment.
- C. Perform thorough hand washing before and after touching any child in the day care center.
- D. Set up a conference with the parents of each child to explain the situation carefully.
Correct Answer: C
Rationale: Thorough hand washing is the most effective measure to prevent the spread of bacterial conjunctivitis.