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.

Encourage the spouse to share their feelings.

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

Offer reassurance that the spouse is not alone.

Answer and Explanation

The Correct Answer is B

Choice A reason: Explaining treatment options is premature and clinical, not addressing the spouse’s emotional loneliness. Encouraging feelings validates their distress, building trust. Treatment discussions can follow after emotional support, ensuring family-centered care, per palliative care and therapeutic communication principles in terminal illness scenarios.

Choice B reason: Encouraging the spouse to share feelings directly addresses their expressed loneliness, promoting therapeutic communication. This validates emotions, assesses coping needs, and fosters rapport, prioritizing psychosocial support in terminal illness. It aligns with family-centered care and palliative nursing principles, ensuring emotional needs are met first.

Choice C reason: Reminding the spouse of potential longevity dismisses their current grief, minimizing feelings. Encouraging emotional expression better supports their immediate needs. This response risks invalidating the spouse’s experience, delaying emotional processing, per psychosocial support and grief management principles in palliative care settings.

Choice D reason: Offering reassurance that the spouse is not alone is supportive but less immediate than exploring feelings. Encouraging emotional expression better assesses their needs, guiding tailored support. Reassurance may seem dismissive without first validating emotions, per therapeutic communication and family support standards in palliative care.

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Correct Answer is B

Explanation

Choice A reason: Warm, dry skin with a low-grade fever suggests infection but is less specific for turning frequency. A Braden score of ten indicates high pressure ulcer risk, prioritizing frequent turning. Fever requires monitoring but not schedule adjustment, per pressure injury prevention and nursing assessment standards.

Choice B reason: A Braden score of ten indicates high pressure ulcer risk, necessitating frequent turning to prevent tissue breakdown. This evidence-based tool directly informs turning schedules, ensuring skin integrity for bedfast clients. It takes precedence over other findings, per pressure injury prevention and nursing care planning protocols.

Choice C reason: 4+ pitting edema increases skin breakdown risk but is secondary to the Braden score, which comprehensively assesses pressure ulcer risk. Turning addresses edema indirectly, but the score guides frequency. Edema requires additional interventions, per pressure injury and fluid management standards in nursing care.

Choice D reason: Hypoactive bowel sounds and infrequent bowel movements indicate constipation, not directly affecting turning frequency. A Braden score of ten prioritizes skin protection via turning. Constipation requires separate management, per gastrointestinal and pressure injury prevention protocols in bedfast client care.

A. Initiate bowel training protocol. B. Advance to a regular diet. C. Offer to warm the prune juice. D. Restrict oral fluid intake.

Correct Answer is C

Explanation

Choice A reason: Initiating a bowel training protocol is premature without addressing immediate constipation. Prune juice, a natural laxative, is appropriate for decreased bowel sounds. Training is for long-term management, not acute relief, per gastrointestinal care and constipation management protocols in nursing practice.

Choice B reason: Advancing to a regular diet is inappropriate, as the mechanical soft diet is likely prescribed for a reason (e.g., dysphagia). Constipation with decreased bowel sounds warrants prune juice, not dietary escalation, which may exacerbate issues, per dietary management and gastrointestinal nursing standards.

Choice C reason: Offering warm prune juice promotes peristalsis, addressing constipation with decreased bowel sounds. Warmth enhances laxative effects, is safe for a mechanical soft diet, and provides immediate relief. This aligns with evidence-based constipation management, ensuring patient comfort, per gastrointestinal and nutritional care protocols.

Choice D reason: Restricting oral fluids worsens constipation by reducing stool hydration. Prune juice increases fluid and fiber, stimulating bowel movement. Decreased bowel sounds indicate sluggish motility, not a need for restriction, per hydration and constipation management principles in gastrointestinal nursing care.

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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

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Correct Answer is B

Explanation

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is documenting wound care in a client’s electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

A client tells the nurse how they hate the way their boss orders them around and never listens to their suggestions. Which response is best for the nurse to provide?

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver is the primary caregiver. While planning care, which problem has the highest priority?

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?