A nurse is caring for a client who is near the end of life and is on complete bed rest.
The client states that he needs to have a bowel movement and the nurse offers a bedpan.
The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

"Tell me what concerns you have about using a bedpan."

"Make sure to use nearby furniture to support yourself when walking to the bathroom."

"You have to use the bedpan for your own safety."

"I will have the physical therapist ambulate you to the bathroom." .

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.

Choice B rationale:

This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.

Choice C rationale:

This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.

Choice D rationale:

Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.

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

Explanation

The correct answers are Choices A, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.

A. Tachycardia B. Lacrimation C. Hypertension D. Urinary retention

Correct Answer is D

Explanation

The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

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A nurse is caring for a client who is near the end of life and is on complete bed rest.The client states that he needs to have a bowel movement and the nurse offers a bedpan.The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

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

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who is near the end of life and is on complete bed rest.
The client states that he needs to have a bowel movement and the nurse offers a bedpan.
The client states, "I've always used the bathroom." Which of the following responses should the nurse make?