A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?

I will take chemotherapy since my family wants me to

I will discuss treatment options next week after thinking about this."

I do not want to have any surgery for my cancer.

I have contacted another surgeon to get a second opinion."

Answer and Explanation

The Correct Answer is A

A) I will take chemotherapy since my family wants me to:

This statement indicates a potential lack of autonomy and decision-making by the client. The nurse should act as a client advocate by ensuring that the client's decisions regarding treatment are based on their own wishes, values, and preferences, rather than solely on the desires of others.

B) I will discuss treatment options next week after thinking about this:

This statement demonstrates the client's intent to participate in the decision-making process regarding their treatment options. While it indicates autonomy and contemplation, it does not necessarily require the nurse to act as a client advocate at this time.

C) I do not want to have any surgery for my cancer:

This statement reflects the client's autonomy and preference regarding their treatment plan. While the nurse should respect the client's decision, it does not directly prompt the nurse to act as a client advocate.

D) I have contacted another surgeon to get a second opinion:

This statement shows the client's proactive approach to gathering additional information about their treatment options, which is commendable. However, it does not specifically indicate a need for the nurse to advocate for the client's rights or preferences.

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

Explanation

A) Ensure the client wears nonskid slippers when walking around the house:

Wearing nonskid slippers can help improve traction and stability, reducing the risk of slips and falls, especially on smooth or slippery surfaces commonly found in homes. Ensuring the client wears nonskid slippers is a proactive measure to prevent falls.

B) Install a raised toilet seat in the client's bathroom:

A raised toilet seat can make it easier for older adults with mobility issues to sit down and stand up from the toilet safely. It reduces the distance the client needs to lower themselves, decreasing the risk of falls, especially for those with balance or strength limitations.

C) Encourage an annual review of the medications the client is taking:

Medication review is essential to identify any medications that may increase the risk of falls due to side effects such as dizziness, drowsiness, or orthostatic hypotension. An annual review ensures that any potential fall-inducing medications can be identified and addressed promptly.

D) Attach full-length side rails to the client's bed:

While side rails may prevent falls out of bed, they can also increase the risk of entrapment and injury. The use of side rails is controversial and should be based on individualized assessment and risk-benefit analysis. In many cases, alternative interventions to prevent falls should be considered before resorting to side rails.

E) Place throw rugs on uncarpeted floors in the client's home:

Throw rugs can be tripping hazards, especially for older adults with mobility issues. They can easily slip or bunch up, leading to falls. Removing throw rugs or securing them firmly to the floor is recommended to reduce the risk of falls in the home.

A. Place the client in a supine position. B. Weigh the client every other day. C. Encourage the client to ambulate three times per day. D. Report urine output less than 30 mL/hr.

Correct Answer is D

Explanation

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

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A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D

Explanation

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