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 B

Explanation

B. A bedside commode allows the client to sit comfortably and maintain independence while toileting. Using a commode chair near the bed reduces the need for bedpan use and promotes mobility.

A. Reassurance is important, but simply reassuring the client without addressing their specific concerns or providing practical solutions may not fully address the issue.

C. Elevating the head of the bed can help with using the bed pan but does not include the other plan of care as a bedside commode would.

D. While positioning the bedpan on the chair may provide an alternative option for the client, it may not be the most practical solution, especially if the client is able to use the bedpan while in bed.

A. Bowel incontinence. B. Impaired bed mobility. C. Caregiver role strain. D. Fluid volume deficit.

Correct Answer is D

Explanation

D. Addressing fluid volume deficit promptly is essential to prevent complications such as hypovolemic shock and renal dysfunction.

A. Bowel incontinence, especially in a client with celiac disease experiencing diarrhea, can lead to skin breakdown, discomfort, and embarrassment. However, it may not be the highest priority if the client's safety and physiological needs are not compromised.

B. Impaired bed mobility after knee replacement surgery can impact the client's recovery, comfort, and risk of complications such as deep vein thrombosis (DVT). However, if the client's condition allows for safe positioning and mobility within bed, this problem may not be the highest priority compared to more immediate concerns.

C. Caregiver role strain is a valid concern, especially if the primary caregiver is experiencing difficulty managing the client's needs. However, the priority is typically focused on addressing the client's immediate physiological needs before addressing caregiver concerns.

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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

Following surgery, a client expresses concern to the nurse about being able to use the bedpan. After noting that the client's prescribed postoperative activity includes getting up to a chair three times a day, how should the nurse intervene?

Correct Answer is B

Explanation

The home health nurse identifies several nursing problems for a client with celiac disease, who had knee replacement surgery 2 weeks ago. The client is experiencing diarrhea and the primary caregiver is the client's spouse. In planning care, which nursing problem has the highest priority?

Correct Answer is D

Explanation

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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?