A nurse is caring for a client who has ovarian cancer and is in the end stages of the dying process.

Provider Prescriptions

Admission: Do-not-resuscitate (DNR) prescription 0940:

Oxycodone acetaminophen 5 mg/325 mg one tablet every 6 hr PRN for pain 1550:

Proceed with withdrawal of mechanically administered nutrition and hydration (MANH)

A nurse is planning care for a client who has requested withdrawal of medically administered nutrition and hydration (MANH). Which of the following should the nurse include in the plan of care? Select all that apply.
(Select All that Apply.)

Support client-requested rituals.

Encourage family to be present for MANH.

Following withdrawal of MANH, offer mouth sponges with preferred flavors as needed.

Request spiritual advisor visit, if applicable

Following withdrawal of MANH, suction oral cavity for pooling of secretions as needed

Educate client on the steps of the dying process

Answer and Explanation

Correct Answer : A,B,C,D,E

Supporting the client's rituals can provide comfort and dignity during this challenging time. It honors their preferences and cultural or religious beliefs, contributing to their overall well-being.

Having loved ones present can offer emotional support to both the client and their family members during the withdrawal of MANH. It allows for meaningful connections and facilitates closure.

Providing mouth sponges with preferred flavors can help alleviate dryness and discomfort in the oral cavity that may occur after the withdrawal of MANH. It promotes comfort and enhances the client's quality of life.

Spiritual support can be valuable for clients and their families during the end-of-life process. If the client desires spiritual guidance or support, arranging for a visit from a spiritual advisor can address their spiritual needs and provide comfort.

Suctioning the oral cavity for pooling secretions can help maintain the client's comfort and prevent aspiration, particularly if the client is unable to swallow effectively. It supports respiratory hygiene and comfort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Cultural beliefs, values, and practices can significantly impact an individual's health behaviors and adherence to medical recommendations.

C. Different cultures may have varied understandings of health and illness, which can affect how they perceive symptoms, seek treatment, and interact with healthcare providers.

D. Healthcare decisions may involve family members, elders, or other community members. Understanding these dynamics is essential for nurses to effectively engage with patients and their families in care planning and decision-making processes.

E. Cultural factors can influence how individuals access and utilize healthcare services. Some cultures may prioritize traditional healing practices or seek care from alternative sources before turning to Western medicine.

B. Power imbalances can actually hinder effective communication and care delivery, especially in cross- cultural encounters

A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct Answer is C

Explanation

Nausea refers to the sensation of feeling sick to the stomach, and it is a symptom that is reported by the client. Since it is based on the client's perception and cannot be directly observed by the nurse, it is considered subjective data.

A. Blood pressure is a measurable vital sign that can be obtained using a blood pressure cuff and stethoscope.

B. Cyanosis is a bluish discoloration of the skin or mucous membranes due to insufficient oxygenation of the blood.

D. Petechiae are small, pinpoint-sized red or purple spots on the skin that result from bleeding under the skin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager in a community clinic is planning an in-service to increase staff nurses' knowledge on cultural diversity in health care. Which of the following information should the nurse manager include in the presentation? (Select All that Apply)

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

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

A nurse is taking a new client's health history at a clinic. Which question should the nurse begin with to obtain the health history?

A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

A nurse is caring for a client who is grieving and has experienced sleep disturbances, weight loss, and often feels angry and irritable. The client also states that they feel depressed. Which of the following assessments is the nurse's priority?

A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?

A 35-year-old woman has been admitted to the hospital for a hysterectomy secondary to uterine cancer caused by smoking, and the nurse is collecting subjective data prior to surgery. Which statements by the nurse could be construed as non-judgmental? (Select All that Apply.)

A nurse is precepting a student nurse interviewing a client with a different cultural background. Which nonverbal behavior by the student indicates that the nurse should intervene? (Select all that apply)