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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.
Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.
Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.
Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.
Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.
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