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. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

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

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

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 is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

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?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.