A hospice nurse is caring for a patient who has terminal cancer and is receiving hospice care for stage 4 metastatic breast cancer.
The patient experiences excruciating pain and is scheduled for morphine 10mg IM every 6 hours. The patient is sleeping, and the medication is due.

What action should the nurse take?

Hold the pain medication until the patient wakes up.

The patient should be given the scheduled pain medication.

Call the family and ask if the patient would like to be woken up to have their pain medication.

The patient has become addicted to the medication and is sleeping the last dose off.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep, and it’s important to keep the patient as comfortable as possible. If the patient is sleeping, it may be because the pain is well-controlled, and delaying the medication could lead to a return of pain.
Choice B rationale
The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient’s pain is managed effectively. Even if the patient is sleeping, the medication should be given to prevent the pain from returning.
Choice C rationale
Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient’s pain level and the medication schedule, not on the family’s preferences.
Choice D rationale
The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case, the patient is receiving the medication for a legitimate medical reason, and there is no indication of addiction.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Neurogenic bladder is a condition where a person lacks bladder control due to a brain, spinal cord or nerve condition. This is not the most fitting answer because the scenario does not provide information about any neurological conditions.
Choice B rationale
Urinary retention can lead to urinary tract infections. The retained urine provides a breeding ground for bacteria, which can lead to infection.
Choice C rationale
Bladder outlet obstruction is a condition where the bladder is not able to empty properly. While urinary retention could be a symptom of this condition, the scenario does not provide enough information to suggest this diagnosis.
Choice D rationale
Genitourinary System Effects is a broad term that refers to any effects on the genital and urinary systems. This is not the most fitting answer because it is less specific than Choice B2.

A. Regression B. Projection C. Rationalization D. Repression

Correct Answer is C

Explanation

Choice A rationale
Regression is a defense mechanism where an individual reverts to an earlier stage of development or a less mature behavior when faced with stress or anxiety. This does not fit the scenario provided. Choice B rationale
Projection involves attributing one’s own unacceptable feelings or thoughts to others. This is not the case in the scenario provided.
Choice C rationale
Rationalization involves creating logical but untrue explanations to justify unacceptable behavior or feelings. In this scenario, the patient is rationalizing their failure to take their medication by blaming their partner’s forgetfulness.
Choice D rationale
Repression involves unconsciously blocking out painful or uncomfortable thoughts or feelings. This does not fit the scenario provided.

Question 14.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a patient who is immobile and is experiencing urinary retention. The nurse should plan to monitor the patient for which of the following?

Correct Answer is B

Explanation

a nurse is caring for a patient who states, “I did not take my medication because my partner forgot to remind me.”. The nurse should identify that the patient is demonstrating which of the following defense mechanisms?

Correct Answer is C

Explanation

A nurse overhears two assistive personnel (APs) disagreeing about patient care assignments. Which of the following actions by the nurse demonstrates conflict resolution?

A nurse is caring for a patient who is scheduled for a surgical procedure. The nurse is reviewing the patient’s electronic medical record. Which of the following findings places the patient at risk for a surgical complication? Select all that apply.

A nurse is teaching a class about stress. The nurse should include that which of the following is an example of chronic stress?

A nurse is educating a group of senior citizens about the physiological changes that occur with aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)

A nurse is preparing to move a patient with left-sided weakness from a seated position in bed to a chair. What actions should the nurse take?

A nurse is conducting a class on stress. Which of the following would the nurse include as an example of acute stress?

A nurse administers the wrong medication to a patient. After assessing the patient, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?