The nurse is caring for a client who is terminally ill and is being transferred to hospice at home. What would the nurse identify as the primary factor in planning the client's care in the home?

Client preferences

Home environment

Socioeconomic status

Family preferences

Answer and Explanation

The Correct Answer is A

A. Client preferences. In hospice care, the client's preferences are the most important factor in planning care. This includes their choices for comfort, treatments, and living arrangements during the end-of-life process.

B. Home environment. While the home environment is important, the client’s wishes and preferences should take precedence in planning their care.

C. Socioeconomic status. Socioeconomic status is not as crucial as the client’s preferences and values in planning hospice care.

D. Family preferences. While family preferences may play a role, the primary focus in hospice care is the client’s wishes for their end-of-life care.

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Correct Answer is A

Explanation

A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.

B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.

C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.

D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.

A. Auscultate for a pericardial friction rub B. Inspect the skin for petechia C. Palpate the radial pulses bilaterally D. Assess for abdominal pain

Correct Answer is A

Explanation

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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The nurse is caring for a client who is terminally ill and is being transferred to hospice at home. What would the nurse identify as the primary factor in planning the client's care in the home?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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