A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which action should the nurse take?

Discuss the risk factors for colon cancer.

Focus on teaching the client about future management of their illness.

Provide the client with written information about the phases of loss and grief.

Reassure the client that this is an expected response to grief.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Discussing the risk factors for colon cancer may not be helpful or comforting to a client who is expressing anger about their diagnosis. It might lead to feelings of guilt or regret if the client feels they could have done something to prevent the disease.

Choice B rationale

Focusing on future management of the illness may be overwhelming for a client who is currently expressing anger about their diagnosis. It might be more beneficial to address the client’s current emotional state before discussing future plans.

Choice C rationale

Providing written information about the phases of loss and grief may be helpful, but it may not address the client’s immediate emotional needs. The client may not be ready to read and process this information while they are expressing anger.

Choice D rationale

Reassuring the client that anger is an expected response to grief can validate the client’s feelings and help them feel understood. It’s important to acknowledge and validate the client’s emotions during this difficult time.

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

Explanation

Choice A rationale

The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.

Choice B rationale

The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.

Choice C rationale

The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.

Choice D rationale

The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.

A. Rock the patient up to a standing position. B. Pivot on the foot that is the farthest from the chair. C. Assess the patient for orthostatic hypotension. D. Apply a gait belt to the patient.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.

Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.

Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.

Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.

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A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.Which three findings require follow-up?

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

Explanation

A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

Correct Answer is C

Explanation

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