Question 1

An obstetric nurse is reviewing risk factors for prenatal loss with a group of clients.Which clients are at a high risk for prenatal loss? Select all that apply.

Accepted Answer

A) The woman who delivered a baby only 6 months ago is at higher risk because her body has not had time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural areas where there may be limited access to healthcare providers also face greater challenges. A gastrointestinal virus will not negatively impact the pregnancy, and those in urban areas have better access to healthcare. One cup of coffee is not excessive intake of caffeine.
B) The woman who delivered a baby only 6 months ago is at higher risk because her body has not had time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural areas where there may be limited access to healthcare providers also face greater challenges. A gastrointestinal virus will not negatively impact the pregnancy, and those in urban areas have better access to healthcare. One cup of coffee is not excessive intake of caffeine.
C) The woman who delivered a baby only 6 months ago is at higher risk because her body has not had time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural areas where there may be limited access to healthcare providers also face greater challenges. A gastrointestinal virus will not negatively impact the pregnancy, and those in urban areas have better access to healthcare. One cup of coffee is not excessive intake of caffeine.
D) The woman who delivered a baby only 6 months ago is at higher risk because her body has not had time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural areas where there may be limited access to healthcare providers also face greater challenges. A gastrointestinal virus will not negatively impact the pregnancy, and those in urban areas have better access to healthcare. One cup of coffee is not excessive intake of caffeine.
E) The woman who delivered a baby only 6 months ago is at higher risk because her body has not had time to fully recover from the previous birth. Adolescents under age 15 are at higher risk, and those living in rural areas where there may be limited access to healthcare providers also face greater challenges. A gastrointestinal virus will not negatively impact the pregnancy, and those in urban areas have better access to healthcare. One cup of coffee is not excessive intake of caffeine.

Question 2

An older adult client whose spouse died 6 months ago tells the nurse stories about the deceased spouse.When care has been completed,the client thanks the nurse for listening and states,"My children will not listen to these stories." From which type of care would this client benefit?

Accepted Answer

A) Treatment of grief in older adults can be successful without medications. Group therapies can be quite effective, as they can be a means of support that the individual may be lacking, as well as a place where the client can discuss any concerns in a judgment-free setting. This type of therapy can also be particularly helpful as it introduces the client to other individuals who have experienced the same loss, and who may be having similar grief responses. For some clients, depending on their personality and preferences, group therapy may not be a good option, but individual therapy may be helpful. Complicated grief is generally treated with a form of psychotherapy called Complicated Grief Treatment, which treats the symptoms of complicated grief while helping the client to move through the grieving process. This client is not demonstrating signs of complicated grief.
B) Treatment of grief in older adults can be successful without medications. Group therapies can be quite effective, as they can be a means of support that the individual may be lacking, as well as a place where the client can discuss any concerns in a judgment-free setting. This type of therapy can also be particularly helpful as it introduces the client to other individuals who have experienced the same loss, and who may be having similar grief responses. For some clients, depending on their personality and preferences, group therapy may not be a good option, but individual therapy may be helpful. Complicated grief is generally treated with a form of psychotherapy called Complicated Grief Treatment, which treats the symptoms of complicated grief while helping the client to move through the grieving process. This client is not demonstrating signs of complicated grief.
C) Treatment of grief in older adults can be successful without medications. Group therapies can be quite effective, as they can be a means of support that the individual may be lacking, as well as a place where the client can discuss any concerns in a judgment-free setting. This type of therapy can also be particularly helpful as it introduces the client to other individuals who have experienced the same loss, and who may be having similar grief responses. For some clients, depending on their personality and preferences, group therapy may not be a good option, but individual therapy may be helpful. Complicated grief is generally treated with a form of psychotherapy called Complicated Grief Treatment, which treats the symptoms of complicated grief while helping the client to move through the grieving process. This client is not demonstrating signs of complicated grief.
D) Treatment of grief in older adults can be successful without medications. Group therapies can be quite effective, as they can be a means of support that the individual may be lacking, as well as a place where the client can discuss any concerns in a judgment-free setting. This type of therapy can also be particularly helpful as it introduces the client to other individuals who have experienced the same loss, and who may be having similar grief responses. For some clients, depending on their personality and preferences, group therapy may not be a good option, but individual therapy may be helpful. Complicated grief is generally treated with a form of psychotherapy called Complicated Grief Treatment, which treats the symptoms of complicated grief while helping the client to move through the grieving process. This client is not demonstrating signs of complicated grief.

Question 3

A client of Native American descent comes to the hospital in early labor at 23 weeks' gestation.The client's parents,sisters,and brothers are with her as well as her husband.The client's family insists on remaining with her during labor.Hospital policy,however,limits visitors to two.Which action is most appropriate for the nurse to take in this situation?

Accepted Answer

A) The mother and the baby's father may be acculturated to contemporary American life enough that they might not want the extended family in attendance even though they know this is traditional. Before confronting the family by asking them to leave or calling security, the parents of the baby are consulted first. If the parents agree to the extra visitors, then seeking the assistance of the manager is inappropriate.
B) The mother and the baby's father may be acculturated to contemporary American life enough that they might not want the extended family in attendance even though they know this is traditional. Before confronting the family by asking them to leave or calling security, the parents of the baby are consulted first. If the parents agree to the extra visitors, then seeking the assistance of the manager is inappropriate.
C) The mother and the baby's father may be acculturated to contemporary American life enough that they might not want the extended family in attendance even though they know this is traditional. Before confronting the family by asking them to leave or calling security, the parents of the baby are consulted first. If the parents agree to the extra visitors, then seeking the assistance of the manager is inappropriate.
D) The mother and the baby's father may be acculturated to contemporary American life enough that they might not want the extended family in attendance even though they know this is traditional. Before confronting the family by asking them to leave or calling security, the parents of the baby are consulted first. If the parents agree to the extra visitors, then seeking the assistance of the manager is inappropriate.

Question 4

A nurse is caring for an older adult client with depression whose spouse died 2 months ago.When planning care for this client,what goals are most appropriate? Select all that apply.

Accepted Answer

A) When planning care for an older adult with normal grief, the nurse will collaborate with the client to develop goals. The goals that the client will attend psychotherapy and complicated grief sessions are not appropriate for a client with normal grief. These therapies are more appropriate for clients with abnormal grieving. All other goals are appropriate.
B) When planning care for an older adult with normal grief, the nurse will collaborate with the client to develop goals. The goals that the client will attend psychotherapy and complicated grief sessions are not appropriate for a client with normal grief. These therapies are more appropriate for clients with abnormal grieving. All other goals are appropriate.
C) When planning care for an older adult with normal grief, the nurse will collaborate with the client to develop goals. The goals that the client will attend psychotherapy and complicated grief sessions are not appropriate for a client with normal grief. These therapies are more appropriate for clients with abnormal grieving. All other goals are appropriate.
D) When planning care for an older adult with normal grief, the nurse will collaborate with the client to develop goals. The goals that the client will attend psychotherapy and complicated grief sessions are not appropriate for a client with normal grief. These therapies are more appropriate for clients with abnormal grieving. All other goals are appropriate.
E) When planning care for an older adult with normal grief, the nurse will collaborate with the client to develop goals. The goals that the client will attend psychotherapy and complicated grief sessions are not appropriate for a client with normal grief. These therapies are more appropriate for clients with abnormal grieving. All other goals are appropriate.

Question 5

A nurse is caring for an older adult client who is experiencing grief after the recent loss of a spouse.What is true regarding an older adult's response to grief?

Accepted Answer

A) Older adults may seem to experience the emotional aspects of grief more acutely than younger adults. Grief in an older adult initially presents similarly to that in a younger adult. Manifestations of grief in older adults are usually more profound than those observed in younger clients. Complicated grief in the older adult manifests as trust issues; this is not a normal manifestation of grief in the older client.
B) Older adults may seem to experience the emotional aspects of grief more acutely than younger adults. Grief in an older adult initially presents similarly to that in a younger adult. Manifestations of grief in older adults are usually more profound than those observed in younger clients. Complicated grief in the older adult manifests as trust issues; this is not a normal manifestation of grief in the older client.
C) Older adults may seem to experience the emotional aspects of grief more acutely than younger adults. Grief in an older adult initially presents similarly to that in a younger adult. Manifestations of grief in older adults are usually more profound than those observed in younger clients. Complicated grief in the older adult manifests as trust issues; this is not a normal manifestation of grief in the older client.
D) Older adults may seem to experience the emotional aspects of grief more acutely than younger adults. Grief in an older adult initially presents similarly to that in a younger adult. Manifestations of grief in older adults are usually more profound than those observed in younger clients. Complicated grief in the older adult manifests as trust issues; this is not a normal manifestation of grief in the older client.

Question 6

The nurse is completing a home care visit of an older adult client who is dying of end-stage renal failure and dementia.The client has been taking narcotic medication for the treatment of chronic arthritic pain.During the visit,the family tells the nurse that the client seems more restless and is grimacing and crying.Which action by the nurse is appropriate?

Accepted Answer

A) Clients with dementia may not be able to accurately express their pain. Other behavior changes, such as agitation, restlessness, and grimacing, often indicate ineffective management of pain. Therefore, adjustments to the pain medication or schedule are warranted. Personality disorders with the presence of dementia are difficult to identify and to differentiate the source of the behavior. Although alternative measures augment pain relief, medications and their administration should be examined as a priority of the assessment.
B) Clients with dementia may not be able to accurately express their pain. Other behavior changes, such as agitation, restlessness, and grimacing, often indicate ineffective management of pain. Therefore, adjustments to the pain medication or schedule are warranted. Personality disorders with the presence of dementia are difficult to identify and to differentiate the source of the behavior. Although alternative measures augment pain relief, medications and their administration should be examined as a priority of the assessment.
C) Clients with dementia may not be able to accurately express their pain. Other behavior changes, such as agitation, restlessness, and grimacing, often indicate ineffective management of pain. Therefore, adjustments to the pain medication or schedule are warranted. Personality disorders with the presence of dementia are difficult to identify and to differentiate the source of the behavior. Although alternative measures augment pain relief, medications and their administration should be examined as a priority of the assessment.
D) Clients with dementia may not be able to accurately express their pain. Other behavior changes, such as agitation, restlessness, and grimacing, often indicate ineffective management of pain. Therefore, adjustments to the pain medication or schedule are warranted. Personality disorders with the presence of dementia are difficult to identify and to differentiate the source of the behavior. Although alternative measures augment pain relief, medications and their administration should be examined as a priority of the assessment.

Question 7

The nurse is caring for a client whose spouse died 3 years ago.The client states to the nurse,"I have dinner with my wife every Saturday night." The client tells the nurse that he includes a table setting for her and prepares their "usual" steak dinner.He also lights a candle for her each week marking the time of her death.Based on this data,which nursing diagnosis is most appropriate for this client when planning care?

Accepted Answer

A) The client exhibits complicated grieving through ritualistic behaviors, and his grieving has not come to the point of resolution after 3 years. Death anxiety is anxiety associated with the anticipation of death. The client is able to perform tasks to care for himself, but he has gone beyond ineffective coping to the dysfunctional. Bereavement is a state of loss that is transient and is not a nursing diagnosis.
B) The client exhibits complicated grieving through ritualistic behaviors, and his grieving has not come to the point of resolution after 3 years. Death anxiety is anxiety associated with the anticipation of death. The client is able to perform tasks to care for himself, but he has gone beyond ineffective coping to the dysfunctional. Bereavement is a state of loss that is transient and is not a nursing diagnosis.
C) The client exhibits complicated grieving through ritualistic behaviors, and his grieving has not come to the point of resolution after 3 years. Death anxiety is anxiety associated with the anticipation of death. The client is able to perform tasks to care for himself, but he has gone beyond ineffective coping to the dysfunctional. Bereavement is a state of loss that is transient and is not a nursing diagnosis.
D) The client exhibits complicated grieving through ritualistic behaviors, and his grieving has not come to the point of resolution after 3 years. Death anxiety is anxiety associated with the anticipation of death. The client is able to perform tasks to care for himself, but he has gone beyond ineffective coping to the dysfunctional. Bereavement is a state of loss that is transient and is not a nursing diagnosis.

Question 8

An older adult client has just learned of the death of an adult child as a result of an automobile accident.The adult child was in another city and died alone.Which action by the nurse is appropriate to address the client during the grieving process?

Accepted Answer

A) The mother and family of the dead son are very likely going to face feelings of guilt for not having been with the son when he died. The nurse plans care for the family and does not obtain a consult unless grief becomes unhealthy. The nurse does not help the family make funeral or burial plans. There is no evidence that the mother or family is experiencing complicated grief at this time.
B) The mother and family of the dead son are very likely going to face feelings of guilt for not having been with the son when he died. The nurse plans care for the family and does not obtain a consult unless grief becomes unhealthy. The nurse does not help the family make funeral or burial plans. There is no evidence that the mother or family is experiencing complicated grief at this time.
C) The mother and family of the dead son are very likely going to face feelings of guilt for not having been with the son when he died. The nurse plans care for the family and does not obtain a consult unless grief becomes unhealthy. The nurse does not help the family make funeral or burial plans. There is no evidence that the mother or family is experiencing complicated grief at this time.
D) The mother and family of the dead son are very likely going to face feelings of guilt for not having been with the son when he died. The nurse plans care for the family and does not obtain a consult unless grief becomes unhealthy. The nurse does not help the family make funeral or burial plans. There is no evidence that the mother or family is experiencing complicated grief at this time.

Question 9

A nurse educator is teaching a group of nursing students about the feelings associated with losing a client.The educator suggests which activity as the most helpful when a nurse is coping with feelings of grief?

Accepted Answer

A) Nurses need closure for their grief in much the same way families do. Attending the wake and/or funeral allows the nurse time to say goodbye and offers support to the family. Keeping a scrapbook of pictures of dead clients is not a healthy way to resolve grief. Taking a week off from work is probably not healthy or realistic. Leaving the unit immediately after the client's death is desertion of a sort. The nurse should stay with the family and give death care with the family to the client, as this will also help with closure.
B) Nurses need closure for their grief in much the same way families do. Attending the wake and/or funeral allows the nurse time to say goodbye and offers support to the family. Keeping a scrapbook of pictures of dead clients is not a healthy way to resolve grief. Taking a week off from work is probably not healthy or realistic. Leaving the unit immediately after the client's death is desertion of a sort. The nurse should stay with the family and give death care with the family to the client, as this will also help with closure.
C) Nurses need closure for their grief in much the same way families do. Attending the wake and/or funeral allows the nurse time to say goodbye and offers support to the family. Keeping a scrapbook of pictures of dead clients is not a healthy way to resolve grief. Taking a week off from work is probably not healthy or realistic. Leaving the unit immediately after the client's death is desertion of a sort. The nurse should stay with the family and give death care with the family to the client, as this will also help with closure.
D) Nurses need closure for their grief in much the same way families do. Attending the wake and/or funeral allows the nurse time to say goodbye and offers support to the family. Keeping a scrapbook of pictures of dead clients is not a healthy way to resolve grief. Taking a week off from work is probably not healthy or realistic. Leaving the unit immediately after the client's death is desertion of a sort. The nurse should stay with the family and give death care with the family to the client, as this will also help with closure.

Question 10

An older adult client with terminal liver disease is concerned about going home and living alone.The client is currently independent with care.The client is afraid of dying alone and does not want to lose control of body functions.Which should the nurse recognize about the client's concerns?

Accepted Answer

A) Common fears of the dying client include death itself; thoughts of a long or painful death; facing death alone; loss of body control, such as bowel and bladder incontinence; and loss of consciousness. Withdrawing and not expressing these fears may be more of a sign of depression than talking about them. They are realistic concerns because they are expressed by the client at this stage. The client is not ready for hospice care because a time frame of 6 months has not been identified and the client is still independent.
B) Common fears of the dying client include death itself; thoughts of a long or painful death; facing death alone; loss of body control, such as bowel and bladder incontinence; and loss of consciousness. Withdrawing and not expressing these fears may be more of a sign of depression than talking about them. They are realistic concerns because they are expressed by the client at this stage. The client is not ready for hospice care because a time frame of 6 months has not been identified and the client is still independent.
C) Common fears of the dying client include death itself; thoughts of a long or painful death; facing death alone; loss of body control, such as bowel and bladder incontinence; and loss of consciousness. Withdrawing and not expressing these fears may be more of a sign of depression than talking about them. They are realistic concerns because they are expressed by the client at this stage. The client is not ready for hospice care because a time frame of 6 months has not been identified and the client is still independent.
D) Common fears of the dying client include death itself; thoughts of a long or painful death; facing death alone; loss of body control, such as bowel and bladder incontinence; and loss of consciousness. Withdrawing and not expressing these fears may be more of a sign of depression than talking about them. They are realistic concerns because they are expressed by the client at this stage. The client is not ready for hospice care because a time frame of 6 months has not been identified and the client is still independent.

Question 11

An older adult client is informed that it is no longer safe for the client to drive at night due to the development of night blindness.Which client statement prompts the nurse to plan a family care conference for the client?

Accepted Answer

A) The client is not being realistic by stating that he still sees okay at night. The nurse realizes that he may continue to drive or may become depressed. A family conference could help assist the client to make safe plans for going out at night. Limiting driving to daytime hours, planning for help to go out at night, and anticipating more hours of daytime in the summer demonstrate acceptance and compliance by the client.
B) The client is not being realistic by stating that he still sees okay at night. The nurse realizes that he may continue to drive or may become depressed. A family conference could help assist the client to make safe plans for going out at night. Limiting driving to daytime hours, planning for help to go out at night, and anticipating more hours of daytime in the summer demonstrate acceptance and compliance by the client.
C) The client is not being realistic by stating that he still sees okay at night. The nurse realizes that he may continue to drive or may become depressed. A family conference could help assist the client to make safe plans for going out at night. Limiting driving to daytime hours, planning for help to go out at night, and anticipating more hours of daytime in the summer demonstrate acceptance and compliance by the client.
D) The client is not being realistic by stating that he still sees okay at night. The nurse realizes that he may continue to drive or may become depressed. A family conference could help assist the client to make safe plans for going out at night. Limiting driving to daytime hours, planning for help to go out at night, and anticipating more hours of daytime in the summer demonstrate acceptance and compliance by the client.

Question 12

The nurse is caring for a client who lost a spouse of 30 years,1 year ago.During care,the client asks the nurse with help in completing certain tasks: pick out a clean shirt,help with shaving,and combing the hair.The client is expecting a visit today from a "special lady friend." Which goal for grieving has this client met?

Accepted Answer

A) The client has met the goal of moving on with his life, demonstrated by the fact that he is planning to see a lady friend and is asking the nurse to help him prepare for the visit. The pain of grief is over at this point or the client would not be interested in company. There is no evidence that the client is disabled or that he has adjusted to the hospital environment and the role of the nurse.
B) The client has met the goal of moving on with his life, demonstrated by the fact that he is planning to see a lady friend and is asking the nurse to help him prepare for the visit. The pain of grief is over at this point or the client would not be interested in company. There is no evidence that the client is disabled or that he has adjusted to the hospital environment and the role of the nurse.
C) The client has met the goal of moving on with his life, demonstrated by the fact that he is planning to see a lady friend and is asking the nurse to help him prepare for the visit. The pain of grief is over at this point or the client would not be interested in company. There is no evidence that the client is disabled or that he has adjusted to the hospital environment and the role of the nurse.
D) The client has met the goal of moving on with his life, demonstrated by the fact that he is planning to see a lady friend and is asking the nurse to help him prepare for the visit. The pain of grief is over at this point or the client would not be interested in company. There is no evidence that the client is disabled or that he has adjusted to the hospital environment and the role of the nurse.

Question 13

The hospice nurse reviews the care provided to a dying client.Which observations indicate that outcomes have been reached for this client? Select all that apply.

Accepted Answer

A) Outcomes for the dying client are centered on physiological comfort and emotional support. A client should never have to fear dying in pain. Desired outcomes include: the client expresses fears related to death or the dying process; the client informs the nurse about increases in pain; the client is made comfortable; the client's family remains informed of any changes in the client's condition. The client expressing the intention to recover from the illness does not demonstrate that care provided has been effective.
B) Outcomes for the dying client are centered on physiological comfort and emotional support. A client should never have to fear dying in pain. Desired outcomes include: the client expresses fears related to death or the dying process; the client informs the nurse about increases in pain; the client is made comfortable; the client's family remains informed of any changes in the client's condition. The client expressing the intention to recover from the illness does not demonstrate that care provided has been effective.
C) Outcomes for the dying client are centered on physiological comfort and emotional support. A client should never have to fear dying in pain. Desired outcomes include: the client expresses fears related to death or the dying process; the client informs the nurse about increases in pain; the client is made comfortable; the client's family remains informed of any changes in the client's condition. The client expressing the intention to recover from the illness does not demonstrate that care provided has been effective.
D) Outcomes for the dying client are centered on physiological comfort and emotional support. A client should never have to fear dying in pain. Desired outcomes include: the client expresses fears related to death or the dying process; the client informs the nurse about increases in pain; the client is made comfortable; the client's family remains informed of any changes in the client's condition. The client expressing the intention to recover from the illness does not demonstrate that care provided has been effective.
E) Outcomes for the dying client are centered on physiological comfort and emotional support. A client should never have to fear dying in pain. Desired outcomes include: the client expresses fears related to death or the dying process; the client informs the nurse about increases in pain; the client is made comfortable; the client's family remains informed of any changes in the client's condition. The client expressing the intention to recover from the illness does not demonstrate that care provided has been effective.

Question 14

The nurse is caring for an adolescent client who has just learned she is pregnant.In order to decrease the risk of perinatal loss with this client,the nurse wants to assess the client for specific risk factors.Which assessment questions are most appropriate to determine the client's risk for perinatal loss?

Accepted Answer

A) Although all pregnant women will be questioned about substance abuse, the nurse will be especially interested in asking an adolescent client about it. Adolescents have a higher rate of substance abuse, and the use of drugs, alcohol, and tobacco can have a negative impact on the outcome of the fetus. All pregnant women will be asked about last menstrual period, diet, and reproductive history. Last menstrual period is of less importance with the young adolescent, whose periods tend to be irregular and cannot be counted on to indicate due date.
B) Although all pregnant women will be questioned about substance abuse, the nurse will be especially interested in asking an adolescent client about it. Adolescents have a higher rate of substance abuse, and the use of drugs, alcohol, and tobacco can have a negative impact on the outcome of the fetus. All pregnant women will be asked about last menstrual period, diet, and reproductive history. Last menstrual period is of less importance with the young adolescent, whose periods tend to be irregular and cannot be counted on to indicate due date.
C) Although all pregnant women will be questioned about substance abuse, the nurse will be especially interested in asking an adolescent client about it. Adolescents have a higher rate of substance abuse, and the use of drugs, alcohol, and tobacco can have a negative impact on the outcome of the fetus. All pregnant women will be asked about last menstrual period, diet, and reproductive history. Last menstrual period is of less importance with the young adolescent, whose periods tend to be irregular and cannot be counted on to indicate due date.
D) Although all pregnant women will be questioned about substance abuse, the nurse will be especially interested in asking an adolescent client about it. Adolescents have a higher rate of substance abuse, and the use of drugs, alcohol, and tobacco can have a negative impact on the outcome of the fetus. All pregnant women will be asked about last menstrual period, diet, and reproductive history. Last menstrual period is of less importance with the young adolescent, whose periods tend to be irregular and cannot be counted on to indicate due date.

Question 15

The novice nurse accepts a job working on a long-term care unit.Nursing care that is required includes caring for clients at the end of life.Which behavior by the nurse indicates a healthy response to the dying client and family?

Accepted Answer

A) The nurse who pays attention to the care of the dying client has most likely dealt with personal feelings and fears regarding death. The nurse in the other options demonstrates a fear of and discomfort with the process of dying.
B) The nurse who pays attention to the care of the dying client has most likely dealt with personal feelings and fears regarding death. The nurse in the other options demonstrates a fear of and discomfort with the process of dying.
C) The nurse who pays attention to the care of the dying client has most likely dealt with personal feelings and fears regarding death. The nurse in the other options demonstrates a fear of and discomfort with the process of dying.
D) The nurse who pays attention to the care of the dying client has most likely dealt with personal feelings and fears regarding death. The nurse in the other options demonstrates a fear of and discomfort with the process of dying.

Question 16

A terminally ill client is demonstrating cognitive signs that the end of life is near.Which assessment findings support the nurse's conclusion? Select all that apply.

Accepted Answer

A) Clients at the end of life may experience confusion as the result of infection, electrolyte abnormalities, medications, illness progression, and pain, as well as from many other causes. During periods of altered consciousness, the client may begin rambling or acting contrary to normal behaviors; concentration is also poor during these periods. Nausea and dry mouth indicate dehydration. Shortness of breath indicates difficulty in breathing that is associated with end of life.
B) Clients at the end of life may experience confusion as the result of infection, electrolyte abnormalities, medications, illness progression, and pain, as well as from many other causes. During periods of altered consciousness, the client may begin rambling or acting contrary to normal behaviors; concentration is also poor during these periods. Nausea and dry mouth indicate dehydration. Shortness of breath indicates difficulty in breathing that is associated with end of life.
C) Clients at the end of life may experience confusion as the result of infection, electrolyte abnormalities, medications, illness progression, and pain, as well as from many other causes. During periods of altered consciousness, the client may begin rambling or acting contrary to normal behaviors; concentration is also poor during these periods. Nausea and dry mouth indicate dehydration. Shortness of breath indicates difficulty in breathing that is associated with end of life.
D) Clients at the end of life may experience confusion as the result of infection, electrolyte abnormalities, medications, illness progression, and pain, as well as from many other causes. During periods of altered consciousness, the client may begin rambling or acting contrary to normal behaviors; concentration is also poor during these periods. Nausea and dry mouth indicate dehydration. Shortness of breath indicates difficulty in breathing that is associated with end of life.
E) Clients at the end of life may experience confusion as the result of infection, electrolyte abnormalities, medications, illness progression, and pain, as well as from many other causes. During periods of altered consciousness, the client may begin rambling or acting contrary to normal behaviors; concentration is also poor during these periods. Nausea and dry mouth indicate dehydration. Shortness of breath indicates difficulty in breathing that is associated with end of life.

Question 17

A client with severe right-sided abdominal pain is experiencing a miscarriage.Which nursing diagnosis is most appropriate for this client?

Accepted Answer

A) A pregnant mother, no matter how early, sees the fetus as a baby and can be expected to grieve the loss. Because the mother has already lost the fetus, Anxiety is not the primary diagnosis. Until the nurse is able to assess the mother's grief process, Ineffective Coping and Interrupted Family Processes are not the priority diagnoses.
B) A pregnant mother, no matter how early, sees the fetus as a baby and can be expected to grieve the loss. Because the mother has already lost the fetus, Anxiety is not the primary diagnosis. Until the nurse is able to assess the mother's grief process, Ineffective Coping and Interrupted Family Processes are not the priority diagnoses.
C) A pregnant mother, no matter how early, sees the fetus as a baby and can be expected to grieve the loss. Because the mother has already lost the fetus, Anxiety is not the primary diagnosis. Until the nurse is able to assess the mother's grief process, Ineffective Coping and Interrupted Family Processes are not the priority diagnoses.
D) A pregnant mother, no matter how early, sees the fetus as a baby and can be expected to grieve the loss. Because the mother has already lost the fetus, Anxiety is not the primary diagnosis. Until the nurse is able to assess the mother's grief process, Ineffective Coping and Interrupted Family Processes are not the priority diagnoses.

Question 18

An older adult client in the terminal phases of a debilitating muscular disease believes the healthcare team has "failed" and "given up" and "aren't trying as hard." On which belief should the nurse plan interventions for this client?

Accepted Answer

A) If the client feels that his terminal state is a reflection of failure of the medical system, this fear of abandonment is common. It may not be totally unfounded because failing to cure a client is frustrating and may reflect in the care provided to the client. Although nurses do provide much of the care given to terminal clients, physicians continue to be an integral part of care. There is no indication of denial in this client's statements, but powerlessness or hopelessness may be evident.
B) If the client feels that his terminal state is a reflection of failure of the medical system, this fear of abandonment is common. It may not be totally unfounded because failing to cure a client is frustrating and may reflect in the care provided to the client. Although nurses do provide much of the care given to terminal clients, physicians continue to be an integral part of care. There is no indication of denial in this client's statements, but powerlessness or hopelessness may be evident.
C) If the client feels that his terminal state is a reflection of failure of the medical system, this fear of abandonment is common. It may not be totally unfounded because failing to cure a client is frustrating and may reflect in the care provided to the client. Although nurses do provide much of the care given to terminal clients, physicians continue to be an integral part of care. There is no indication of denial in this client's statements, but powerlessness or hopelessness may be evident.
D) If the client feels that his terminal state is a reflection of failure of the medical system, this fear of abandonment is common. It may not be totally unfounded because failing to cure a client is frustrating and may reflect in the care provided to the client. Although nurses do provide much of the care given to terminal clients, physicians continue to be an integral part of care. There is no indication of denial in this client's statements, but powerlessness or hopelessness may be evident.

Question 19

The home health nurse visiting an older Israeli client for a routine medication check determines that the client has declined since the last home visit.The nurse suggests that the client should be transported to the hospital; however,the family members state that they want the client to stay in the home.Which action by the nurse is most appropriate?

Accepted Answer

A) Many cultures see death as inevitable, and in such cases the clients often prefer to die in their homes with their families. The nurse should ascertain that this is what the client wishes and respect that. Calling for an ambulance is inappropriate, as is encouraging the family to take the client to a hospital against their wishes. The nurse would not follow the family's wishes without finding out what the client wants.
B) Many cultures see death as inevitable, and in such cases the clients often prefer to die in their homes with their families. The nurse should ascertain that this is what the client wishes and respect that. Calling for an ambulance is inappropriate, as is encouraging the family to take the client to a hospital against their wishes. The nurse would not follow the family's wishes without finding out what the client wants.
C) Many cultures see death as inevitable, and in such cases the clients often prefer to die in their homes with their families. The nurse should ascertain that this is what the client wishes and respect that. Calling for an ambulance is inappropriate, as is encouraging the family to take the client to a hospital against their wishes. The nurse would not follow the family's wishes without finding out what the client wants.
D) Many cultures see death as inevitable, and in such cases the clients often prefer to die in their homes with their families. The nurse should ascertain that this is what the client wishes and respect that. Calling for an ambulance is inappropriate, as is encouraging the family to take the client to a hospital against their wishes. The nurse would not follow the family's wishes without finding out what the client wants.

Question 20

A hospice nurse is caring for a client who has been given 6 months to live.Which nursing intervention would address the anxiety of the client and family associated with receiving a terminal diagnosis?

Accepted Answer

A) It is most helpful for the nurse to know how the client and family have dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. The need for discussion and the amount of time needed will vary from client to client, so "dwelling" is an inappropriate descriptor. The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. Early use of anti-anxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to think clearly about the future.
B) It is most helpful for the nurse to know how the client and family have dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. The need for discussion and the amount of time needed will vary from client to client, so "dwelling" is an inappropriate descriptor. The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. Early use of anti-anxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to think clearly about the future.
C) It is most helpful for the nurse to know how the client and family have dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. The need for discussion and the amount of time needed will vary from client to client, so "dwelling" is an inappropriate descriptor. The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. Early use of anti-anxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to think clearly about the future.
D) It is most helpful for the nurse to know how the client and family have dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis. The need for discussion and the amount of time needed will vary from client to client, so "dwelling" is an inappropriate descriptor. The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed. Early use of anti-anxiety and sedative medications is not appropriate because these medications can adversely affect the client's ability to think clearly about the future.

Quiz 27: Grief and Loss