The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Verify the client's code status.

Begin cardiopulmonary resuscitation.

Provide comfort measures until family arrives.

Initiate a slow code response.

Answer and Explanation

The Correct Answer is B

A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.

B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.

C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.

D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.

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Correct Answer is C

Explanation

A. "Have you been trying to lose weight?" This response does not address the caregiver’s concern about losing weight due to lack of time and may seem to dismiss their situation.

B. "You must take care of yourself or you will not be able to care for your partner." While this statement is true, it may be perceived as accusatory and could lead to feelings of guilt or resentment.

C. "What are some things you are doing to take care of yourself?" This is a good response as it encourages the caregiver to think about their self-care practices and opens a dialogue about their well-being.

D. "It is often easy to lose weight when we become busy and distracted." This response might minimize the caregiver’s concern and does not provide practical support or solutions.

A. "How would you describe your sleep problem?" B. "What types of sleep treatments have you tried?" C. "What do you think is the cause of the sleep problem?" D. "How does the sleep problem affect your everyday living?" E. "Don't you think when you get tired enough, you'll sleep well?"

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

Explanation

A. "How would you describe your sleep problem?" Understanding how the patient describes their sleep problem provides insight into the nature of the disturbance and its potential causes.

B. "What types of sleep treatments have you tried?" Knowing what treatments have been tried helps identify what has or hasn’t worked and can guide further management.

C. "What do you think is the cause of the sleep problem?" Understanding the patient’s perspective on the cause can help in assessing their awareness and any possible underlying issues.

D. "How does the sleep problem affect your everyday living?" This question assesses the impact of sleep disturbances on daily life and overall well-being, providing context for the severity of the problem.

E. "Don't you think when you get tired enough, you'll sleep well?" This statement does not address the underlying problem and might dismiss the patient’s concerns. It is not useful in assessing or managing sleep disturbances.

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The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is visiting with a client with terminal cancer whose partner has become the primary caregiver. The partner states, "Maybe I will lose weight since I rarely have time to eat." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

The nurse is reviewing sleep habits with a patient who reports difficulty sleeping. When evaluating sleep disturbances, the nurse should ask which of the following? Select all that apply.

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

Explanation

The nurse is teaching a patient about good sleep hygiene habits. Which of the following information should the nurse include?

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