The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

You have plenty of time to figure all of that out."

"Decisions will then be made for your spouse by the health care provider."

"Decisions should be made now for your spouse's future."

I can explain advance care planning to you."

Answer and Explanation

The Correct Answer is D

A. "You have plenty of time to figure all of that out." This response is not proactive and may not address the urgency of planning for future decisions. It is important to address these issues sooner rather than later.

B. "Decisions will then be made for your spouse by the health care provider." Healthcare providers will make decisions based on medical criteria and the patient's current condition, but they will typically follow the wishes expressed in advance directives or legal documents.

C. "Decisions should be made now for your spouse's future." This is a proactive approach, but it's important to involve the spouse in the decision-making process.

D. "I can explain advance care planning to you." This is the most appropriate response. Advance care planning involves discussing the client's wishes regarding their future care, including decisions about life-sustaining treatments. By explaining this process, the nurse can help the spouse prepare for a time when the client may be unable to make their own decisions.

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Correct Answer is B

Explanation

A. Gait belt with handles: A gait belt can provide support and stability during transfers, but it is generally used for walking rather than transferring directly from bed to chair.

B. Lateral-assist transfer board: A lateral-assist transfer board can help with moving the patient from bed to chair by sliding, making it appropriate for this transfer scenario.

C. Powered stand-assist aid: A powered stand-assist aid is typically used to help patients who need assistance standing and could be appropriate if the patient requires more support during the transfer.

D. Powered full-body lift: A powered full-body lift is generally used for patients who cannot bear weight at all and would not be necessary for a patient who can bear weight on one leg and use a walker.

A. The client with breast cancer who had a mastectomy. B. The client with chronic obstructive pulmonary disease who requires oxygen therapy. C. The client with colon cancer who has a colostomy. D. The client with a left upper arm fracture who was a victim of a crime.

Correct Answer is D

Explanation

A. The client with breast cancer who had a mastectomy. This client is facing a significant life change and physical alteration that may lead to psychosocial stressors such as body image issues and emotional distress.

B. The client with chronic obstructive pulmonary disease who requires oxygen therapy. Although this condition is challenging, the primary stressors are often physical and related to the management of the disease rather than psychosocial stressors.

C. The client with colon cancer who has a colostomy. A colostomy can affect body image and self-esteem, potentially leading to psychosocial stressors such as anxiety or social isolation.

D. The client with a left upper arm fracture who was a victim of a crime. The fracture and the trauma of being a crime victim are significant psychosocial stressors. The emotional and psychological impact of the crime can affect the client’s overall mental health.

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The nurses talking with the spouse of an older adult client who has been diagnosed with dementia. The spouse states, "What will I do when my spouse cannot make decisions anymore?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to transfer a patient from the bed to a chair next to the bed. The patient has full weight bearing on the right leg and partial weight bearing on the left leg. They use a walker when ambulating. Which of the following assistive devices would be appropriate for the transfer?

Correct Answer is B

Explanation

The nurse is assessing a group of clients for psychosocial stressors. Which of the following client's should the nurse identify as having this type of stressor?

Correct Answer is D

Explanation

The nurse is assisting a client with performing range-of-motion of the shoulder and the client asks the nurse to identify each movement performed. Which of the following movements should the nurse include? Select all that apply.

The nurse is assisting a client, who is postoperative abdominal surgery, to the chair. The nurse notes the client is guarding the abdomen and grimacing when ambulating. Which of the following would be the most appropriate question or statement by the nurse?

The nurse is caring for a client that fell at home and is planning to move in with their adult child. Which of the following statements, by the client, would require immediate follow up by the nurse?

The nurse is assisting a client, from the bed into a wheelchair, who had a right-side below the knee amputation one day ago. The client states, "I will not be able to do much because of this wheelchair." The client is demonstrating which of the following defense mechanisms?

The nurse is preparing to administer prescribed modified (cloudy) and nonmodified (clear) insulin to a client with type 1 diabetes. Place the following steps in the correct order, that the nurse should take to prepare the medication. All options must be used.

The nurse is assessing clients for risk factors of experiencing developmental stress. Which of the following clients should the nurse identify has having a risk factor?

The nurse is caring for a patient diagnosed with a terminal illness who is interested in signing a healthcare Advanced Directive. Which of the following are included in this type of end-of-life planning? Select all that apply.