The nurse is caring for a patient who has just died. What is the priority action of the nurse?

Ask the family to leave the room so that post-mortem care can be provided.

Provide post-mortem care in a manner consistent with religious pr cultural beliefs.

Have the patient's family members sign consent forms for organ donation.

Remove all drainage tubes and IV lines in case an autopsy is to be performed.

Answer and Explanation

The Correct Answer is B

A. Ask the family to leave the room so that post-mortem care can be provided: Families should be given the option to be present unless they decline or it conflicts with facility policy or religious/cultural norms.

B. Provide post-mortem care in a manner consistent with religious or cultural beliefs: Respecting the patient’s and family’s cultural/religious practices is essential in end-of-life care and is the priority.

C. Have the patient's family members sign consent forms for organ donation: Organ donation discussions are usually conducted by trained personnel or coordinators, not the bedside nurse.

D. Remove all drainage tubes and IV lines in case an autopsy is to be performed: Tubes and lines should not be removed if an autopsy is pending, as they may be required for the investigation.

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Correct Answer is C

Explanation

A. Restless
This is observable-an objective finding.

B. Alert
Also objective and part of a mental status assessment.

C. Anxiety
Anxiety is a subjective experience-it’s what the client reports feeling.

D. Pacing
This is observable and thus objective.

A. "When I look in the mirror, all I see is a person without a leg." B. "If my wife had paid more attention to my blood sugar levels I would not have needed an amputation." C. "I have not always made good choices in life. I deserve to lose my leg." D. "No matter how hard I work in physical therapy. I can't seem to make any progress."

Correct Answer is A

Explanation

a. "When I look in the mirror, all I see is a person without a leg.":
This statement reflects distorted body image, focusing entirely on the physical loss and indicating a disturbance in self-perception.

b. "If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.":
This reflects blame or anger, not necessarily a body image disturbance.

c. "I have not always made good choices in life. I deserve to lose my leg.":
This reflects guilt or low self-worth, which is more emotional or spiritual distress than body image-specific.

d. "No matter how hard I work in physical therapy, I can't seem to make any progress.":
This shows frustration with recovery, not necessarily about the client's body image.

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The nurse is caring for a patient who has just died. What is the priority action of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who reports feeling stress and anxiety. The client appears restless and is pacing. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

Correct Answer is C

Explanation

A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?

Correct Answer is A

Explanation

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