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. Amyloid plaque: Amyloid plaque buildup is characteristic of Alzheimer’s disease, a chronic, progressive form of dementia. While dementia can increase the overall risk for delirium, amyloid plaques themselves are not an immediate trigger for acute confusion like delirium.

B. Urinary tract infection: Urinary tract infections are a common reversible cause of delirium, especially in older adults. Infections can trigger a systemic inflammatory response and disrupt normal brain function, leading to sudden-onset confusion, disorientation, and restlessness due to systemic inflammation and changes in metabolic balance.

C. High cholesterol: High cholesterol contributes to long-term cardiovascular risks, such as atherosclerosis and stroke, but it is not directly linked to the sudden cognitive changes seen in delirium. It does not cause the acute neurological dysfunction characteristic of delirium.

D. Hypersomnia: Hypersomnia, or excessive daytime sleepiness, may reflect underlying sleep disorders or other chronic conditions, but it is not recognized as a common direct cause of delirium. Acute changes in mental status are more often tied to factors like infection, medications, or metabolic disturbances.

A. Hypertension B. Muscle cramps C. Blurred vision D. Constipation

Correct Answer is B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

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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

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