The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Request a spiritual advisor's consult.

Encourage viewing of the body to accept the death.

Provide support of the spouse's feelings.

Ask the relatives about how the spouse is coping.

Answer and Explanation

The Correct Answer is C

A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.

B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.

C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.

D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.

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Correct Answer is ["C","D","E"]

Explanation

A. Monitor ETT markings between 22 and 26 cm at teeth line: While the placement marking on the ETT can be useful for initial placement, it is not the most reliable way to confirm correct positioning. ETT placement should always be verified by clinical assessment rather than relying solely on measurements.

B. Check for capillary refill of 3 seconds or less: Capillary refill is a general indicator of peripheral circulation and does not directly assess whether the ETT is properly placed in the trachea. It is not useful for confirming ETT placement.

C. Auscultate for presence of bilateral breath sounds: This is a key assessment to confirm that the ETT is properly placed. Bilateral breath sounds indicate that air is entering both lungs, suggesting that the tube is correctly positioned in the trachea and not in the esophagus.

D. Obtain a portable chest x-ray to verify ETT location: A chest x-ray is the gold standard for confirming the correct placement of the ETT. It provides an accurate visual confirmation of the tube’s position relative to the carina and the lungs.

E. Assess for symmetrical chest movement: Symmetrical chest movement is another important assessment to confirm proper ETT placement. If the ETT is correctly placed in the trachea, both sides of the chest will rise and fall equally with each breath, indicating effective ventilation.

A. Pain scale. B. Skin integrity. C. Bowel sounds. D. Functional ability E. Heart sounds.

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

Explanation

A. Pain scale: Pain is a key symptom of Herpes zoster (shingles), and the effectiveness of treatment is often measured by the relief of pain. The nurse should assess the pain level regularly using a pain scale to evaluate the effectiveness of pain management interventions.

B. Skin integrity: Herpes zoster causes a rash and blisters, and monitoring skin integrity is important to assess for signs of infection, healing, or any new areas of skin breakdown. The healing of the rash and blisters is a key indicator of treatment effectiveness.

C. Bowel sounds: Bowel sounds are not related to the treatment or condition of Herpes zoster. While important in other contexts, they are not a relevant assessment for evaluating the effectiveness of shingles treatment.

D. Functional ability: Functional ability, including the client’s ability to perform activities of daily living, can be impacted by the pain and discomfort associated with shingles. Assessing functional ability helps to gauge the overall impact of the condition and the effectiveness of treatment in improving quality of life.

E. Heart sounds: Heart sounds are not directly related to the treatment of Herpes zoster. This assessment is not necessary for evaluating the effectiveness of shingles treatment unless there are unrelated cardiovascular concerns.

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The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

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

Explanation

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