A nurse is providing care for a patient who has terminal liver cancer.
Which statement from the patient should the nurse recognize as a sign of spiritual distress?

“What did I do to deserve this illness?”

“I blame medical science for not finding a cure.”.

“Where is my daughter when I need her most?”

“Will I ever regain control over my life?”

Answer and Explanation

The Correct Answer is A

Choice A rationale

The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be

questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.

Choice B rationale

The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.

Choice C rationale

The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.

Choice D rationale

The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².

Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.

Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.

Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.

Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.

A. Insert the needle at a 15-degree angle. B. Aspirate for blood return before administration. C. Administer the medication into the abdomen. D. Massage the site after the injection.

Correct Answer is C

Explanation

Choice A rationale

Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.

Choice B rationale

Aspirating for blood return before administration is not necessary when administering heparin.

Choice C rationale

Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.

Choice D rationale

Massaging the site after the injection is not recommended as it can cause bruising.

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A nurse is providing care for a patient who has terminal liver cancer.Which statement from the patient should the nurse recognize as a sign of spiritual distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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A nurse is providing care for a patient who has terminal liver cancer.
Which statement from the patient should the nurse recognize as a sign of spiritual distress?