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 ["A","B","E"]

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

A. Encourage the use of incontinence briefs. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Insert a rectal tube at specified intervals.

Correct Answer is B

Explanation

B. This timing is based on the gastrocolic reflex, which typically triggers bowel movements shortly after eating. By assisting the client to the commode after meals, the nurse can take advantage of this reflex and increase the likelihood of successful bowel evacuation, reducing the risk of fecal incontinence episodes.

A. Incontinence briefs can provide containment for fecal incontinence and help manage soiling of clothing and bedding. However, they do not address the underlying issue of fecal incontinence or contribute to bowel training.

C. Administering a glycerin suppository after meals may stimulate bowel movements, but it does not address the underlying causes of fecal incontinence or promote bowel training.

D. Inserting a rectal tube at specified intervals may be indicated for fecal management in certain clinical situations, but it is not typically used as a primary intervention for bowel training in clients with chronic fecal incontinence.

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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 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.

Correct Answer is ["A","B","E"]

Explanation

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?

Correct Answer is B

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

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?

The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

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

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

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