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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Correct Answer is ["B","C"]

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Begins to discuss how their partner and children are important to them B. Asks to change the topic during the interview process C. Discusses reasons for making a behavior change D. Requests more information about treatment options

Correct Answer is C

Explanation

Discussing the client's reasons for change is a key component of eliciting and strengthening motivation. When the client voluntarily discusses their reasons for making a behavior change, it suggests that they are beginning to articulate and explore their motivations.

A. This behavior indicates successful engagement with the client.

B. This behavior may indicate resistance or ambivalence toward discussing the target behavior change.

D. This behavior may indicate a readiness to explore treatment options but does not necessarily indicate successful engagement with the client in MI.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

A nurse is interviewing a client who is contemplating a behavior change. According to the processes of Motivational Interviewing, which of the following client behaviors indicates that the nurse has successfully engaged with the client?

Correct Answer is C

Explanation

A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

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

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?