Homework Lance
1. A client has a terminal illness and is discussing future treatments with the nurse. The nurse notes that he has not been eating and his response to the nurse’s information is, “What does it matter?” The most appropriate nursing diagnosis for this client is:
1.
Denial
2.
Hopelessness
3.
Social isolation
4.
Spiritual distress
ANS: 2
A defining characteristic for the nursing diagnosis of hopelessness may include the client stating, “What does it matter?” when offered choices or information concerning themselves. Also, the client’s behavior of not eating is an indicator of hopelessness. The client’s behavior and verbalization do not indicate denial. This is not an example of social isolation. The client is not avoiding or restricted from seeing others. Spiritual distress is not the most appropriate nursing diagnosis for this client. The focus needs to be on the client’s lack of hope.
PTS: 1 DIF: A REF: 470 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
2. One of the benefits of anticipatory grieving to a client or family is that it can:
1.
Be done in private
2.
Be discussed with others
3.
Promote separation of the ill client from the family
4.
Help a person progress to a healthier emotional state
ANS: 4
The benefit of anticipatory grief is that it allows time for the process of grief (i.e., to say good-bye and complete life affairs). Anticipatory grief allows time to grieve in private, to discuss the anticipated loss with others, and to “let go” of the loved one. Anticipatory grief can help a person progress to a healthier emotional state of acceptance and dealing with loss. It is not most beneficial for grieving to take place only in private. It is important for grief to be acknowledged by others, and to be able to receive the support of others in the grieving process. Anticipatory grieving can be discussed with others in most circumstances. However, there may be times when anticipatory grief is disenfranchised grief as well, meaning it cannot be openly acknowledged, socially sanctioned, or publicly shared, such as a partner dying of AIDS. The benefit of anticipatory grieving is not so much that it can be discussed in most circumstances, as this discussion can also occur with normal grief when the actual loss has occurred. Anticipatory grief is the process of disengaging or “letting go” that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill client from the family as much as it is the process of being able to say good-bye and to put life affairs in order, and as a result, it can help a client or family to progress to a higher emotional state.
PTS: 1 DIF: A REF: 463 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
3. A newly graduated nurse is best prepared for the assignment of his first dying patient if he:
1.
Completed a course dealing with death and dying
2.
Is able to control his own personal emotions about death
3.
Has previously experienced the death of a dear loved one
4.
Has developed a personal understanding of his own feelings about death
ANS: 4
When caring for clients experiencing grief, it is important for the nurse to assess his or her own emotional well-being and to understand his or her own feelings about death. The nurse who is aware of his or her own feelings will be less likely to place personal situations and values before those of the client. Although coursework on death and dying may add to the nurse’s knowledge base, it does not best prepare the nurse for caring for a dying client. The nurse needs to have an awareness of his or her own feelings about death first, as death can raise many emotions. Being able to control one’s own emotions is important; however, it is unlikely the nurse would be able to do so if he or she has not first developed a personal understanding of his or her own feelings about death. Experiencing the death of a loved one is not a prerequisite to caring for a dying client. Experiencing death may help an individual mature in dealing with loss, or it may invoke many negative emotions if there is complicated grief present. The nurse is best prepared by first developing an understanding of his or her own feelings about death.
PTS: 1 DIF: C REF: 465 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
4. The family of a client with a terminal illness will be able to help provide some psychological support to their family member. To assist the family to meet this outcome, the nurse plans to include in the teaching plan:
1.
Demonstration of bathing techniques
2.
Application of oxygen delivery devices
3.
Recognition of the client’s needs and fears
4.
Information on when to contact the hospice nurse
ANS: 3
A dying client’s family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears. Demonstration of bathing techniques may help the family meet the dying client’s physical needs, not in providing psychological support. Application of oxygen devices may help the family provide physical needs for the client, not in providing psychological support for the client. Information on when to contact the hospice nurse is important knowledge for the family to have and may help them feel they are being supported in caring for the dying client. However, contact information does not help the family provide psychological support to the dying client.
PTS: 1 DIF: A REF: 474 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
5. A client that was recently diagnosed with a terminal illness asks his nurse about organ donation. The nurse should:
1.
Have the client first discuss the subject with the family
2.
Suggest the client delay making a decision at this time
3.
Assist the client to obtain the necessary information to make this decision
4.
Contact the client’s physician so consent can be obtained from the family
ANS: 3
No topic that a dying client wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As client advocate, the nurse should assist the client to obtain the necessary information to make this decision. The nurse should provide the client with information in order to make such a decision. Although the nurse may suggest that the client discuss this option after having obtained information, it is up to the client to discuss the subject with the family. The nurse should respect the client and provide the necessary information for him or her to make a decision rather than dismissing the client’s question. It is not necessary to contact the physician or the family for consent for organ donation if the client is capable of making this decision.
PTS: 1 DIF: A REF: 469-470 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
6. A client, who is receiving chemotherapy on a medical unit due to a recent diagnosis of terminal cancer of the liver, has an in-depth conversation with the nurse. The client says, “This cannot be happening to me.” The nurse identifies that this stage is associated with, according to Kübler-Ross:
1.
Anxiety
2.
Denial
3.
Confrontation
4.
Depression
ANS: 2
According to Kübler-Ross, the client is in the denial stage of dying. The client may act as though nothing has happened, may refuse to believe or understand that a loss has occurred, and may seem stunned, as though it is “unreal” or difficult to believe. There is no stage of anxiety in the five stages of dying of Kübler-Ross. There is no stage of confrontation in the five stages of dying of Kübler-Ross. During depression the individual may feel overwhelmingly lonely and withdraw from interpersonal interaction.
PTS: 1 DIF: A REF: 464 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
7. A client who is Chinese American has just died on the unit. The nurse is prepared to provide after-death care to the client and anticipates the probable preferences of a family from this cultural background will include:
1.
Pastoral care
2.
Preparation for organ donation
3.
Time for the family to bathe the client
4.
Preparation for quick removal out of the hospital
ANS: 3
Some families of Chinese Americans will prefer to bathe the client themselves. They often believe the body should remain intact; organ donation and autopsy are uncommon. Chinese Americans do not prefer pastoral care for after-death care of a family member. Organ donation is uncommon for Chinese Americans. Chinese Americans may desire time to bathe the client. Quick removal from the hospital is not preferred.
PTS: 1 DIF: A REF: 466 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
8. The nurse is providing care to a dying client. Which of the following is the primary concern? The nurse should:
1.
Promote optimism in the client and be a source of encouragement
2.
Promote dignity and self-esteem in as many interventions as is appropriate
3.
Allow the client to be alone and expect isolation on the part of the dying person
4.
Intervene in the client’s activities and promote as near normal functions as possible
ANS: 2
The focus in planning nursing care is to support the client physically, emotionally, developmentally, and spiritually in the expression of grief. When caring for the dying client, it is important to devise a plan that helps a client to die with dignity and offers family members the assurance their loved one is cared for with care and compassion. Optimism should not be the primary focus when caring for the dying client. The nurse should promote the client’s self-esteem and allow the client to die with dignity. The client does not need to be left alone. The nurse’s or family’s presence may be comforting to the client by showing that he or she is being cared for and is worthy of attention. The client should be allowed to make choices and perform as many activities of daily living independently as possible. This allows the client to maintain self-esteem and dignity.
PTS: 1 DIF: A REF: 481 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
9. There is a different focus for the client with hospice nursing care. The nurse is aware that client care provided through a hospice is:
1.
Designed to meet the client’s individual wishes, as much as possible
2.
Aimed at offering curative treatment plans intended for client recovery
3.
Involved in teaching families and/or caregivers to provide postmortem care
4.
Offered primarily for hospitalized clients for whom at-home care is not possible
ANS: 1
The nurse’s role in hospice is to meet the primary wishes of the dying client and to be open to individual desires of each client. The nurse supports a client’s choice in maintaining comfort and dignity. Hospice care is for the terminally ill. It is not aimed at offering curative treatment, but rather the emphasis is on palliative care. Hospice care may provide bereavement follow-up for the family after a client’s death, but hospice nurses typically do not teach the family postmortem care. Hospice care is primarily for home care, but a client in a hospice may become hospitalized.
PTS: 1 DIF: A REF: 475 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
10. To provide comfort for the client, while preparing to assist the client in the end stage of her life in response to anticipated symptom development, the nurse plans to:
1.
Decrease the client’s fluid intake
2.
Limit the use of over-the-counter analgesics
3.
Provide larger meals with more appealing seasoning
4.
Determine valued activities and schedule rest periods
ANS: 4
To promote comfort in the terminally ill client, the nurse should help the client to identify values or desired tasks; then help the client to conserve energy for those tasks. Decreasing the client’s fluid intake may make the terminally ill client more prone to dehydration and constipation. The nurse should take measures to help maintain oral intake, such as administering antiemetics, applying topical analgesics to oral lesions, and offering ice chips. The use of analgesics should not be limited. Controlling the terminally ill client’s level of pain is a primary concern in promoting comfort. Nausea and vomiting and anorexia may increase the terminally ill client’s likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable.
PTS: 1 DIF: A REF: 471 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
11. To maintain the client’s sense of self-worth during the end of life while working with a client in an inpatient hospice unit, the nurse should:
1.
Leave the client alone to deal with final affairs
2.
Call upon the client’s spiritual advisor to manage care
3.
Include regular visits throughout the day into the client’s care plan
4.
Facilitate the arrangements to have a grief counselor visit the client
ANS: 3
Spending time to let clients share their life experiences, particularly what has been meaningful, enables the nurse to know clients better. Knowing clients then facilitates choice of therapies that promote client decision-making and autonomy. Planning regular visits also helps the client maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurse’s time and attention. The client should not be left alone to feel abandoned or isolated. Nurses can help clients meet spiritual needs by facilitating connections to a spiritual practice or community and supporting the expression of culturally held beliefs. A client’s spiritual advisor may also be called upon but is not the only source of spiritual support. The nurse who turns care over to the spiritual advisor is not promoting the client’s sense of self-worth, as it may imply the client is not worthy of the nurse’s time or attention. A grief counselor may be requested to visit if the client is experiencing complicated grief. Having a grief counselor visit is not an intervention that will help maintain a client’s sense of self-worth.
PTS: 1 DIF: A REF: 477 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
12. A nursing intervention to assist the client with a nursing diagnosis of sleep pattern disturbance related to the loss of spouse and fear of nightmares should be to:
1.
Administer sleeping medication per order
2.
Refer the client to a psychologist or psychotherapist
3.
Have the client complete a detailed sleep pattern assessment
4.
Sit with the client while encouraging verbalization of feelings
ANS: 4
A nursing intervention to facilitate grief work is to offer the client encouragement to explore and verbalize feelings of grief. This encouragement refocuses the client on current needs and minimizes dysfunctional adaptation behaviors (e.g., not sleeping) by facilitating resolution of grief through problem-solving skills. Administering sleeping medication may help the client get to sleep but does not resolve the issue of grief. Without addressing the grief, the client may develop another dysfunctional adaptation behavior. It is not necessary to refer the client to a psychologist or psychotherapist at this time. The client needs to be encouraged to verbalize his or her feelings. Having the client complete a detailed sleep pattern assessment may help the nurse identify the number of hours of sleep the client is obtaining, but it does not address the issue causing the sleep disturbance, which is grief from the loss of the spouse.
PTS: 1 DIF: A REF: 468 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
13. To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should:
1.
Provide mouth care
2.
Offer high-protein foods
3.
Increase the fluid intake
4.
Offer a high-residue diet
ANS: 2
To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should administer antiemetics, provide oral care at least every 2 to 4 hours, offer clear liquid diet and ice chips, avoid liquids that increase stomach acidity (such as coffee, milk, and citrus acid juices), and offer high-protein foods in smaller portions and of a bland nature. Oral care should be provided every 2 to 4 hours. Increasing the fluid intake may help prevent constipation. A low-residue diet may help prevent diarrhea.
PTS: 1 DIF: A REF: 476 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
14. A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to:
1.
Limit fluids
2.
Position the client upright
3.
Reduce narcotic analgesic use
4.
Administer bronchodilators as needed
ANS: 2
Positioning the client upright is an independent nursing intervention for the promotion of respiratory function in a terminally ill client. Limiting fluids may not promote respiratory function, and unless a client is on a fluid-restricted diet, the nurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before administering narcotics to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician’s order. It is not an independent nursing activity.
PTS: 1 DIF: A REF: 476 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
15. The nurse is using Bowlby’s phases of mourning as a framework for assessing the client’s response to the traumatic loss of her leg. During the “yearning and searching” phase, the nurse anticipates that the client may respond by:
1.
Crying intermittently
2.
Becoming angry at the nurse
3.
Acting stunned by the eventual loss
4.
Discussing the change in role that will occur
ANS: 1
During the “yearning and searching” phase of Bowlby’s phases of mourning, the nurse anticipates the client may have outbursts of tearful sobbing and acute distress. During Bowlby’s “disorganization and despair” phase of mourning, the nurse anticipates the client may express anger at anyone who might be responsible, including the nurse.
During the “numbing” phase of Bowlby’s phases of mourning, the nurse anticipates the client may act stunned by the loss. During the “reorganization” phase of Bowlby’s phases of mourning, the nurse anticipates the client may discuss the change in role that will occur.
PTS: 1 DIF: A REF: 464 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
16. The nurse finds a client who has been diagnosed with terminal lung cancer quietly crying. Which of the following nursing responses most reflects a need for additional guidance regarding therapeutic communication with a dying client?
1.
“If there is anything I can do to help, just ask.”
2.
“Would you like some medication to help you sleep?”
3.
“Do you want me to call your wife so you two can talk?”
4.
“Try not to be sad; let’s find something to be thankful for.”
ANS: 4
Avoid communication barriers such as denying the client’s grief, providing false reassurance, or avoiding discussion of sensitive issues. Remember that a client’s emotions are not something you can “fix.” Instead, view emotional expression as a necessary part of the client’s adjustment to significant life changes and development of effective coping skills.
PTS: 1 DIF: C REF: 468 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
17. A terminally ill client shares with the nurse that he, “needs to tell someone what I want when the end comes.” The nurse’s most therapeutic response is:
1.
“We can talk about that now if you want to. Let me close the door and pull up a chair.”
2.
“I imagine you would like to discuss matters with your primary care provider. I’ll let him know you want to talk.”
3.
“Let me finish with my client care, I’ll be back in 10 minutes, and we can talk as long as you need to.”
4.
“If you haven’t discussed your feelings with your family yet, I’d suggest you do that when they visit this evening.”
ANS: 1
Avoid communication barriers such as denying the client’s grief, providing false reassurance, or avoiding discussion of sensitive issues. When you sense that a client wants to talk about something, make time right then, if at all possible.
PTS: 1 DIF: C REF: 469-470 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
18. The wife of a client recently diagnosed with end-stage renal failure shares with the nurse that, “He just accepts this; I want a second opinion.” The nurse recognizes that while the client has reached the acceptance stage of grieving, his wife is experiencing the:
1.
Anger stage
2.
Denial stage
3.
Depression stage
4.
Bargaining stage
ANS: 1
In the denial stage, a person acts as though nothing has happened and refuses to accept the fact of the loss. The person shows no understanding of what has occurred. When experiencing the anger stage of adjustment to loss, a person expresses resistance and sometimes feels intense anger at God, other people, or the situation. Bargaining cushions and postpones awareness of the loss by trying to prevent it from happening. Grieving or dying people make promises to self, God, or loved ones that they will live or believe differently if they can be spared the dreaded outcome. When a person realizes the full impact of the loss, depression occurs. Some individuals feel overwhelmingly sad, hopeless, and lonely. Resigned to the bad outcome, they sometimes withdraw from relationships and life. In acceptance, the person incorporates the loss into life and finds ways to move forward.
PTS: 1 DIF: A REF: 464 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
19. The mother of a child who was killed in an automobile accident is diagnosed with excessive grief. The nurse realizes that this diagnosis increases her risk of:
1.
Attempting suicide
2.
Developing anorexia nervosa
3.
Becoming chronically depressed
4.
Developing a psychiatric phobia
ANS: 1
Normal grief responses, when experienced in excess, become overwhelming. People who exhibit very intense emotions and severe symptoms lose control, appear deeply traumatized, or may become suicidal, requiring medication or stabilization before they are able to begin the healing process. Depression is possible but is triggered by a variety of events. Grief is not the typical trigger for either anorexia nervosa or phobias.
PTS: 1 DIF: A REF: 463 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
20. The nurse recognizes that which of the following clients is at greatest risk for complicated (dysfunctional) grief?
1.
A 26-year-old who is diagnosed with rheumatoid arthritis
2.
The 58-year-old only child whose mother recently died of cancer
3.
A teenage parent whose child died of sudden infant death syndrome (SIDS)
4.
A 50-year-old diabetic client who has experienced an above-the-knee amputation
ANS: 3
Loss associated with homicide, suicide, sudden accidents, or the loss of a child has the potential to become complicated.
PTS: 1 DIF: C REF: 463 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
21. Experiencing normal grief over losses allows the adolescent to successfully:
1.
Move past the loss
2.
Regain a sense of security
3.
Develop effectual coping skills
4.
Deal with an actual loss later in life
ANS: 3
Normal grief experiences often help persons to mature and develop coping methods for dealing with other losses in the future. The remaining options are facets of successfully coping with loss.
PTS: 1 DIF: A REF: 463 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
22. A client who recently experienced an amputation of the left thumb has a perceived loss of physical attractiveness. The nurse recognizes that such a loss is:
1.
More easily assessed than actual losses
2.
Much less personal than an actual loss
3.
Universally experienced by all amputees
4.
Capable of producing grief similar to an actual loss
ANS: 4
Perceived losses are easy to overlook because they are so internally and individually experienced, although they are grieved in the same way as an actual loss. The express of grief over a loss, perceived or real, is a very individualized, personal response.
PTS: 1 DIF: C REF: 463 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
23. Which of the following nursing assessment data best reflects the successful achievement of the dying client’s right to be pain free?
1.
Introducing the client to effective alternative pain management techniques
2.
Educating the client on the appropriate use of a patient-controlled analgesia device
3.
Pain rated as a 3 out of 10 after the administration of the prescribed pain medication
4.
Informed the primary care provider of the client’s need for additional pain medication.
ANS: 3
The client is entitled to a pain free death. The most reflective assessment data supporting such a situation is a pain rating of 3 out of 10. The remaining options are all directed toward to that end.
PTS: 1 DIF: C REF: 462 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
24. Which of the following interventions best reflects the nurse’s attempt to honor the terminally ill client’s cultural values?
1.
Interviewing both the client and the family to identify preferred end-of-life care
2.
Talking openly and without biases about the client’s end-of-life care preferences
3.
Providing the family with the opportunity to realize the client’s end-of-life wishes
4.
Becoming familiar with the death rituals most common among the nurse’s client population
ANS: 3
Care provided at the end-of-life within the client and family’s cultural context draws on the resources of their entire lives. Honoring client and family cultural values characterizes expert end-of-life care. Actually facilitating the opportunity to have the client’s wishes fulfilled is the best reflection of expert end-of-life care. The other options are all facets of being successful at facilitating this care.
PTS: 1 DIF: C REF: 475 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
25. Which of the following statements, made by a nurse regarding the means by which older adults usually express and manage grief, reflects a need for further instruction and clarification?
1.
“The greater the loss the greater the sense of grief.”
2.
“Managing depression will help the grieving adult cope.”
3.
“Having lived a long, happy life makes grieving easier to deal with.”
4.
“The longer you live, the more experience you have with grieving a death.”
ANS: 3
There is little evidence that grief experiences differ due to age alone. Responses to loss are more likely related to the nature of the specific loss experience. Increased age increases the likelihood that older adults have faced multiple losses—loved ones, friends, valued objects, outliving a child, or declining health. Depression does make dealing with grief more difficult.
PTS: 1 DIF: C REF: 478 OBJ: Analysis
TOP: Nursing Process: Analysis
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
26. A terminally ill client is reporting a sense of anxiety and dyspnea. The nurse’s initial intervention is to:
1.
Assess the client’s vital signs and administer the prescribed antianxiety medication
2.
Determine the cause of the client’s dyspnea and provide both emotional and physical support
3.
Position the client in a semi-Fowler’s position and provide supplemental oxygen via nasal cannula
4.
Remain with the client and encourage him to express the concerns he is experiencing regarding his death
ANS: 3
Position for comfort and maximal respiratory excursion, provide supplemental O2. Then provide comforting, reduce anxiety or fever; provide effective pain management as appropriate. The initial intervention when a client is experiencing respiratory difficulties, no matter what the potential cause it to facilitate breathing through appropriate positioning and administration of oxygen.
PTS: 1 DIF: C REF: 463 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
27. The nurse most effectively addresses the protection of a terminally ill, incontinent client’s skin from irritation and breakdown by:
1.
Using adult diapers and changing them as soon as they become wet or otherwise soiled
2.
Assessing the client’s bed frequently for wetness and assuring clean, dry linens and clothing
3.
Securing an order for an indwelling catheter and keeping the perineal area free of fecal matter
4.
Offering the client frequent opportunities to toilet and responding promptly to requests to toilet
ANS: 2
Progressive disease and decreased level of consciousness can result in both urinary and fecal incontinence. The most effective means of protect skin from irritation or breakdown is by maintaining dry linens and clothing. The remaining options are not inappropriate, but a client may not be able to respond to the need to urinate or defecate. While adult diapers and an indwelling catheter are viable interventions, the client must still be provided with care that ensures that skin will be clean and dry.
PTS: 1 DIF: C REF: 476 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
28. In order to most effectively address the discomfort of limited oral fluid intake for a client in the latter stages of the dying process, the nurse should:
1.
Provide mouth care at least every 2 hours
2.
Offer ice chips each time the client is visited
3.
Provide the client frequent sips of a favorite beverage
4.
Moisten the client’s lips with an appropriate water based lubricant
ANS: 1
Client is less willing or able to maintain oral fluid intake reduce discomfort from dehydration by providing mouth care at least every 2 to 4 hours. Lubricating the client’s lips should be included in mouth care while the other options may be impractical if the client is unable or unwilling to take fluids orally.
PTS: 1 DIF: C REF: 476 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
29. The son of a client in the initial stage of the dying process is concerned that, “Mom just isn’t eating much.” The nurse responds most therapeutically by answering:
1.
“Her body systems are beginning to shut down and she just doesn’t need as much food.”
2.
“Her pain medication may be making her nauseated. Has she complained or been vomiting?”
3.
“We can off her frequent, small portions of her favorite foods. Can you suggest some things she might enjoy?”
4.
“Right now solid foods are not as important as drinking. Just be sure she continues to take in plenty of fluids.”
ANS: 3
Medications, depression, decreased activity, decreased blood flow to the gastrointestinal tract; nausea produces anorexia. Offer smaller portions of client preferred foods. Treat underlying cause of anorexia. Do not force food on actively dying client. While the other options are not inaccurate, the most therapeutic response offers the son an appropriate action that might encourage his mother’s eating.
PTS: 1 DIF: C REF: 476 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
30. The nurse is caring for a terminal ill client in the final stages of the death process when the client’s daughter asks, “Why are you putting drops in dad’s eyes?” The nurse responds more accurately by telling the daughter that:
1.
“His blinking reflex is gone and these drops lubricate his corneas.”
2.
“The drops will keep the corneas moist since you have donated them.”
3.
“They are artificial tears that will keep his eyes from becoming dry and painful.”
4.
“They were prescribed for him but I won’t instill them if you prefer that I don’t”
ANS: 3
Blinking reflexes diminish near death, causing drying of the cornea. Optical lubricants or artificial tears reduce corneal drying. While the other options are accurate, they do not address the daughter’s question as thoroughly as the identification of and reasoning for the drops.
PTS: 1 DIF: C REF: 476 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
31. A terminal ill client’s pain is being managed with opioid analgesics. When he reports experiencing constipation, the nurse’s most therapeutic response is:
1.
“It’s a side effect of the pain medication you are taking.”
2.
“I’ll discuss adding some additional bulk to your diet with your wife.”
3.
“Try drinking more liquids while you are awake to help soften your stool.”
4.
“I’ll see about getting a prescription for a laxative in order to avoid the problem.”
ANS: 4
While constipation is a common side effect of opioid analgesics, the most therapeutic nursing response to the client’s report is to offer an appropriate intervention. While the other options are appropriate, the use of a laxative is likely to produce the most effective, timely solution to the problem especially since a terminally ill client is not likely to be eating and drinking sufficiently.
PTS: 1 DIF: A REF: 476 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
32. Which of the following statements shows the best understanding of Kübler-Ross’s Five Stages of Dying?
1.
“Crying is an expected behavior of the Depression Stage.”
2.
“There are tasks the client completes as they work toward acceptance.”
3.
“People grieve in the manner in which they are most culturally comfortable”
4.
“Given enough time and support, most achieves acceptance of their own death.”
ANS: 2
Survivors move back and forth through a series of stages and/or tasks many times, possibly extending over a long period of time. Theorists described stages of the grieving process and a series of tasks for survivors to successfully complete their bereavement and adapt to life with a loss. Why the other options are true, they do not show the best overall understanding of the Five Stages of Dying.
PTS: 1 DIF: C REF: 476 OBJ: Analysis
TOP: Nursing Process: Analysis
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. The daughter of a terminally ill client is grieving the inevitable death of her parent. The expression and depth of her grieve is most likely impacted by her: (Select all that apply.)
1.
Spiritual beliefs
2.
Chronological age
3.
Developmental stage
4.
Culturally influences
5.
Past experiences with loss
6.
Level of formal education
ANS: 1, 4, 5
Grief is the emotional response to a loss, manifested in ways unique to an individual, based on personal experiences, cultural expectations, and spiritual beliefs. The remaining options have minimal effect on individual grieving
PTS: 1 DIF: A REF: 464 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
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