A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

"We can discuss this after completing the admission process."

"Your partner is in the denial stage of grief."

"You should discuss this problem with your family members."

"Your partner is experiencing an expected response to the dying process."

Answer and Explanation

The Correct Answer is D

A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.

B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.

C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.

D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.

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Correct Answer is B

Explanation

A. Tortuous veins: Tortuous veins indicate varicosities, which are typically a chronic condition and not an immediate sign of deep-vein thrombosis (DVT). While they can be associated with venous insufficiency, they do not require urgent reporting for DVT suspicion.

B. Calf swelling: Calf swelling, especially if unilateral, is a classic sign of DVT and suggests venous obstruction by a thrombus. This finding requires prompt reporting to prevent complications such as pulmonary embolism.

C. Bradycardia: Bradycardia is unrelated to DVT and is not an expected finding in this condition. It does not indicate thrombotic complications and does not require immediate reporting in this context.

D. Clammy skin: Clammy skin can be a nonspecific sign related to many conditions such as shock or anxiety but is not a primary indicator of DVT. It does not necessitate urgent reporting for DVT unless accompanied by other concerning signs.

A. Have the client perform heel-to-toe walking. B. Perform Weber's test. C. Check for a positive Babinski reflex. D. Perform the Romberg test. E. Have the client lie in bed and use his heel to draw a line on the opposite shin.

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

Explanation

A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.

B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.

C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.

D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.

E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.

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A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

Nursing Test Bank

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

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