A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider.

Which of the following actions should the nurse take?

Change the subject when the client becomes upset.

Discourage the client from forming new relationships.

Allow the client unlimited time for the grieving process

Offer the client advice about various treatment choices.

Answer and Explanation

The Correct Answer is C

A.   Changing the subject when the client becomes upset may invalidate their feelings and hinder emotional expression and processing.
B.   Discouraging the client from forming new relationships may deprive the client of potentially meaningful connections during their remaining time.
C.   Allowing the client unlimited time for the grieving process acknowledges the client's emotional response to their diagnosis and respects their individual needs and coping mechanisms.

D. Offering advice about treatment choices may be appropriate in some situations but should be done in collaboration with the client's healthcare team and in consideration of their wishes and values.

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Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. Provide written information about the client's treatment plan. B. Encourage countertransference when developing the nurse-client relationship. C. Monitor the client for splitting behaviors. D. Isolate the client from social or group interactions.

Correct Answer is A

Explanation

A. Providing written information about the treatment plan promotes transparency and helps to establish trust with the client, which is important in the care of individuals with paranoid personality disorder.
B. Encouraging countertransference can blur professional boundaries and may exacerbate distrust or suspicion in clients with paranoid personality disorder.

C. Monitoring for splitting behaviors is important in personality disorders but does not directly address the client's needs or promote therapeutic engagement.
D. Isolating the client from social or group interactions can exacerbate feelings of paranoia and may not be therapeutic or appropriate.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

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A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider.

Which of the following actions should the nurse take?