A nurse is caring for a client who has cancer and is terminally ill.
The client reports feeling depressed.
Which of the following statements should the nurse make?
Would you like to speak to a spiritual advisor
Do you need a prescription for an antianxiety medication
Would you like to talk to a counselor about advance directives
Do you need information on hospice care
The Correct Answer is A
The correct answer is choice A. “Would you like to speak to a spiritual advisor?”.
This statement shows respect for the client’s spirituality and offers support without imposing the nurse’s beliefs or values. Spirituality focuses on the significance and purpose of life and can help clients cope with depression and terminal illness.
Choice B is wrong because it implies that the client needs medication to deal with their feelings, which can be dismissive and insensitive.
Antianxiety medication may be appropriate for some clients, but it should not be the first option.
Choice C is wrong because it assumes that the client is ready to discuss advance directives, which may not be the case.
Advance directives are legal documents that specify the client’s wishes for end-of-life care, such as resuscitation, organ donation, or power of attorney.
The nurse should assess the client’s readiness and understanding before initiating this conversation.
Choice D is wrong because it suggests that the client is close to death and needs hospice care, which can be discouraging and frightening. Hospice care is an interdisciplinary team effort that provides palliative care for clients who have a terminal illness and a life expectancy of less than 6 months.
The nurse should explain the benefits of hospice care and obtain the client’s consent before making a referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, a noncoring needle.
A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point.
A noncoring needle also reduces the risk of infection and clotting.
Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.
It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
Choice C is wrong because a 25-gauge needle is too small to access a port.
A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.
Correct Answer is B
Explanation
The correct answer is choice B, bradypnea. Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A, euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C, constipation, is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D, sedation, is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
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