An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon.
The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stays a few more days. Which is the most appropriate initial response by the nurse?
"I will let the health care provider know that you want to be discharged and do everything I can to make it happen.”.
"Tell me more about your need to leave the hospital.”.
"I will ask the palliative care nurse to talk with you to help clarify your care goals.”.
"I understand your desire to leave, but it would be very risky
The Correct Answer is B
Choice B rationale
Using an open-ended statement encourages the client to express their feelings and motivations, which is a key component of therapeutic communication. In the context of a terminal diagnosis and impending paralysis, the client may be experiencing the denial or anger stages of grief. By asking the client to tell more, the nurse validates the client's autonomy and provides a safe space for them to process their emotions. This assessment must occur before any further interventions or referrals are made.
Choice A rationale
This response is premature and potentially irresponsible as it avoids the nurse's duty to assess the client's emotional state. Simply agreeing to facilitate discharge without understanding the underlying distress or ensuring a safe transition home ignores the clinical risks of spinal metastasis. While advocacy is important, it must be balanced with the nursing process. Jumping straight to discharge planning without exploring the client's sudden change in perspective fails to address the psychological crisis the client is currently facing.
Choice C rationale
While palliative care is appropriate for a terminal diagnosis, suggesting a referral immediately may feel dismissive to the client. The nurse should first establish a therapeutic rapport and understand the client's immediate concerns. Passing the conversation to another professional too quickly can make the client feel unheard or like a burden. Effective nursing involves direct engagement with the client's expressed needs. The nurse must first perform a focused assessment of the client's psychological readiness to discuss long-term goals.
Choice D rationale
Telling the client their desire is risky is a non-therapeutic response that can be perceived as patronizing or demeaning. It uses a "yes, but" approach that invalidates the client's feelings and shuts down further communication. In a crisis, clients need empathy and a chance to speak, not a lecture on medical risks. While safety is a priority, delivering this information bluntly can damage the nurse-client relationship and prevent the nurse from uncovering the true reason why the client wants to leave.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Taking a fire extinguisher to the room follows the acronym PASS, but in the sequence of fire safety represented by the acronym RACE, extinguishing the fire is the very last step. The nurse must first ensure that the alarm is sounded to alert the entire facility and the fire department. Attempting to fight a fire before the alarm is activated could lead to the fire spreading unnoticed by others, which puts the entire building and all occupants at risk.
Choice B rationale
While calling 911 is an important part of emergency response, pulling the fire alarm is a faster and more efficient way to alert all personnel in a hospital setting. The fire alarm system is often directly linked to the fire department and simultaneously activates internal alerts and fire doors. Relying solely on a phone call may delay the immediate localized response needed to contain the situation. The alarm ensures that the specific location of the fire is identified.
Choice C rationale
According to the RACE acronym, which stands for Rescue, Alarm, Confine, and Extinguish, the second action after rescuing the client is to activate the fire alarm. This ensures that the fire department is notified and that all staff members are aware of the emergency. Promptly pulling the alarm allows the facility to begin its established fire protocols, which are essential for the safety of everyone in the building. It is the most critical next step.
Choice D rationale
Evacuating all clients on the nursing unit is a later step in the fire safety protocol, typically occurring if the fire cannot be contained or if ordered by the fire marshal. The immediate priority after removing the person in danger is to sound the alarm. Evacuation is a complex and high-risk process that should be coordinated based on the severity and location of the fire. Moving too many people prematurely can create chaos and block the access of emergency responders.
Correct Answer is D
Explanation
Choice A rationale
Surfactant is a complex mixture of phospholipids and proteins produced by type II alveolar cells. Its primary scientific function is to reduce surface tension at the air-liquid interface within the alveoli, preventing them from collapsing during expiration. While surfactant is essential for maintaining the structural integrity of the lungs and efficient breathing, it is a chemical substance rather than the anatomical site where gas exchange occurs.
Choice B rationale
Bronchioles are small airway passages that lead from the bronchi to the alveolar sacs. They are primarily composed of smooth muscle and lack cartilage. Their main role is the conduction of air and the regulation of airflow resistance through bronchoconstriction and bronchodilation. Although they are deep within the respiratory tree, the walls of the bronchioles are too thick to allow for the rapid diffusion of gases into the bloodstream.
Choice C rationale
The trachea, or windpipe, is a large cartilaginous tube that connects the larynx to the bronchi. It serves as the primary conduit for air entering and exiting the lower respiratory tract. The trachea is lined with ciliated pseudostratified columnar epithelium to trap and move debris. Because of its thick walls and protective cartilage rings, no gas exchange takes place here; it functions strictly as a passageway.
Choice D rationale
The alveoli are tiny, grape-like clusters of thin-walled sacs located at the terminal ends of the respiratory tree. They are the primary site of gas exchange because their walls consist of a single layer of squamous epithelium. This thinness allows oxygen to diffuse from the air into the surrounding pulmonary capillaries while carbon dioxide diffuses from the blood into the alveoli to be exhaled.
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