A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Be honest with the client about their prognosis.

Include the client's input when setting treatment goals.

Keep an agreement made with the client to administer an antiemetic medication

Administer pain medication to the client on a routine schedule.

Answer and Explanation

The Correct Answer is B

A. Be honest with the client about their prognosis: Honesty is essential for building trust but does not alone promote autonomy. Autonomy specifically involves allowing the client to make informed decisions about their own care based on truthful information.

B. Include the client's input when setting treatment goals: Including the client’s input directly supports their autonomy by allowing them to actively participate in decisions about their care, treatments, and end-of-life goals, ensuring their personal values and wishes are respected.

C. Keep an agreement made with the client to administer an antiemetic medication: Honoring agreements builds trust and supports ethical practice but focuses more on fidelity than directly on promoting autonomy, which centers on the client’s decision-making role.

D. Administer pain medication to the client on a routine schedule: Providing pain management is important for comfort but does not by itself promote autonomy unless it involves client participation in deciding how and when the medication is administered.

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Correct Answer is B

Explanation

A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.

B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.

C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.

D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.

A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6° C (99.7° F) B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10 C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding D. A child who had a cast placed 4 hr ago and reports numb in the affected extremity

Correct Answer is D

Explanation

A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.

B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.

C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.

D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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