The nurse is providing end-of-life care and determines the patient is experiencing critical distress related to concerns about the afterlife. Which portion of the nursing process should the nurse use to guide the plan of care?

Planning.

Assessment.

Analysis.

Implementation.

Answer and Explanation

The Correct Answer is A

Choice A reason: Planning guides end-of-life care by developing interventions to alleviate anxiety about the future, identified during assessment. Anxiety activates the amygdala, increasing stress hormones. Planning may include spiritual support or counseling, addressing psychological needs to reduce distress, ensuring a tailored care plan promotes comfort and dignity at end-of-life.

Choice B reason: Assessment identifies anxiety but does not guide the care plan directly. It collects data (e.g., verbalized fears) about future concerns, while planning translates this into interventions, like spiritual care. Anxiety’s physiological effects (e.g., elevated cortisol) require targeted strategies, making planning the step to address these needs effectively.

Choice C reason: Analysis interprets data to diagnose anxiety, but the question states it’s already identified. Planning follows, creating interventions to reduce end-of-life distress, such as meditation or family involvement. Anxiety disrupts emotional regulation via the limbic system, requiring a structured plan to implement relief, making analysis secondary here.

Choice D reason: Implementation enacts the care plan, but anxiety about the future requires planning to design interventions first. Actions like providing spiritual resources follow action development to address psychological distress. Anxiety increases sympathetic activity, and planning ensures interventions target this, making implementation premature without a defined strategy.

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Correct Answer is B

Explanation

Choice A reason: Blood pressure reflects hemodynamic status but is less specific for fluid balance. Fluid overload increases preload, raising blood pressure, but fluctuations may occur from other causes (e.g., stress). Daily weight directly measures fluid changes, as 1 kg equals 1 L of fluid, providing precise data for diuresis efficacy, making this secondary.

Choice B reason: Daily weight is the most accurate assessment for fluid balance, as 1 kg of weight change equals 1 L of fluid. Fluid overload, often from renal or cardiac issues, increases extracellular volume. Monitoring weight tracks diuresis effectiveness, guiding fluid management to restore homeostasis, making this the primary assessment for overload.

Choice C reason: Lung sounds (e.g., crackles) indicate pulmonary edema from fluid overload but are less precise than weight. Fluid in alveoli impairs gas exchange, but sounds vary with position or breathing. Weight provides quantitative fluid data, essential for tracking diuresis progress, making lung sounds a supportive, not primary, assessment.

Choice D reason: Skin turgor assesses dehydration, not fluid overload. Overload causes edema, stretching skin, but turgor is unreliable for excess fluid. Daily weight quantifies fluid changes, directly correlating with volume status. Turgor is more relevant for fluid deficit, making it inappropriate for evaluating diuresis in a client with overload.

A. Demonstrate how the medication will be taken. B. Ask the client for any additional questions. C. Recognize sources of confusion for the client. D. Inquire about frequency of administration.

Correct Answer is D

Explanation

Choice A reason: Demonstrating medication administration teaches, not evaluates understanding. Inquiring about frequency confirms the client’s knowledge of the regimen, ensuring adherence. Demonstration is an instructional method, not an assessment tool, per patient education and medication safety standards in nursing practice.

Choice B reason: Asking for additional questions identifies gaps but does not directly assess understanding of the regimen. Inquiring about frequency evaluates specific knowledge critical for adherence. Questions are supplementary, per patient education and comprehension assessment principles in medication teaching protocols.

Choice C reason: Recognizing confusion is part of teaching but not a direct evaluation of understanding. Inquiring about frequency tests retention of key information, ensuring safe administration. Confusion assessment is indirect, per medication education and patient comprehension standards in nursing care.

Choice D reason: Inquiring about frequency of administration directly evaluates the client’s understanding of the prescription, confirming knowledge of dosing intervals critical for adherence and safety. This targeted question assesses retention, guiding further teaching if needed, per patient education and medication safety protocols in nursing practice.

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The nurse is providing end-of-life care and determines the patient is experiencing critical distress related to concerns about the afterlife. Which portion of the nursing process should the nurse use to guide the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client’s fluid balance?

Correct Answer is B

Explanation

The nurse is providing teaching to a client who receives a new medication prescription. Which action should the nurse use to evaluate the client’s understanding?

Correct Answer is D

Explanation

A client’s spouse has just learned of the client’s terminal illness. The spouse is sitting in the corner of the client’s room crying and says to the nurse, “I feel as if I’m already so alone.” Which action should the nurse take first?

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

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The nurse is providing oral care for a client who is unconscious. To safely perform the task, which action should the nurse take?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

When entering a client’s room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?