A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Explain that alternative treatment options may be helpful.

Remind the spouse that the client may still live a long time.

Offer reassurance that the spouse is not alone.

Encourage the spouse to share their feelings.

Answer and Explanation

The Correct Answer is C

C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.

A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.

D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.

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Correct Answer is D

Explanation

D. To assess fever patterns accurately in a client with a fever of unknown origin, the nurse should measure the temperature at regular intervals. This helps in identifying trends and patterns in the fever, such as spikes at specific times of the day or consistent elevations. Regular temperature measurements provide valuable information for the healthcare team to diagnose and manage the underlying cause of the fever effectively.

A. Assessing for flushed, warm skin can be indicative of fever, due to vasodilation and skin flushing. While this assessment can provide subjective clues about the presence of fever, it does not provide comprehensive information about fever patterns over time.

B. Different sites may reflect variations in temperature due to local factors or differences in blood flow. However, while varying sites can contribute to a comprehensive assessment of body temperature, it does not specifically address the need to assess fever patterns over time.

C. While circadian rhythms can influence temperature variations, particularly in relation to sleep- wake cycles, documenting circadian rhythms alone does not provide specific information about fever patterns.

A. Contraction of the left pupil when light shines in the right eye. B. Active bowel sounds in the lower right quadrant. C. Capillary refill of 2 seconds in the lower right foot. D. Basilar lung sounds that are diminished in the left lung.

Correct Answer is D

Explanation

A chart by exception system requires nurses to document deviations from the expected or normal findings rather than documenting every single detail.

D All lung zones should have clear vesicular breath sounds. The presence of diminished sounds indicated lung consolidation which can occur in pneumonic processes or pleural effecusion.

A This finding indicates a normal response known as a consensual response, where the left pupil constricts when light is shone into the right eye.

B Active bowel sounds are considered normal and indicate proper gastrointestinal motility.

C Capillary refill is a quick bedside test used to assess peripheral circulation and tissue perfusion. A refill time of 2 seconds is within the normal range (typically 2 seconds or less), indicating adequate perfusion.

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A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is D

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is D

Explanation

The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The healthcare provider prescribes cefuroxime 5 grams every 8 hours IM for a client with pneumonia. The available vial is labeled, "Cefuroxime 500 mg/mL." How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required round to the nearest whole number.)

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is providing safety instructions to a client who is being discharged home with oxygen therapy. Which information provided by the client indicates understanding?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?