A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do?

Call a partial code.

Call a code.

Call the physician.

Call a "slow code."

Answer and Explanation

The Correct Answer is B

In the absence of an advance directive, the nurse should call a code ³. This means initiating emergency resuscitation measures to try to revive the client. The other options (Call a partial code, Call the physician, and Call a "slow code") are not appropriate in this situation.

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Correct Answer is C

Explanation

Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.

A. Risk for Injury B. Altered Tissue Perfusion C. Impaired Tissue Integrity D. Impaired Skin Integrity

Correct Answer is D

Explanation

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

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A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

Correct Answer is C

Explanation

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Correct Answer is D

Explanation

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

How would a nurse document the condition in which a client has a normal state of awareness?

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

A client has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital. Which one of the following stages of illness is this client experiencing?

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?

A nurse is providing care for a client who has recently been diagnosed with type 1 diabetes mellitus. To focus on aﬀective learning with this client, the nurse should use which of the following interventions?