The plan of care for a client who was recently diagnosed with breast cancer includes the nursing problem, "Anxiety related to the threat of death secondary to the cancer diagnosis." Which expected outcome should the nurse identify for this client?

Cries openly when discussing diagnosis.

Describes acceptance of impending death.

Verbalizes feelings when becoming anxious.

Uses coping mechanisms effectively.

Answer and Explanation

The Correct Answer is C

A. Crying openly when discussing the diagnosis is an emotional response but does not indicate effective management of anxiety. While it may be part of the grieving process, it is not a measurable or achievable outcome for anxiety reduction.

B. Describing acceptance of impending death may be an unrealistic or premature outcome for a client who has just been diagnosed with cancer. Immediate nursing goals should focus on managing anxiety rather than expecting full acceptance of mortality.

C. Verbalizing feelings when becoming anxious is an appropriate and measurable expected outcome. It demonstrates that the client is able to recognize and communicate anxiety, allowing the nurse to provide support, teach coping strategies, and monitor emotional adjustment. This outcome is realistic and achievable in the short term and directly addresses the nursing problem of anxiety.

D. Using coping mechanisms effectively is a desirable long-term goal, but it is broad and difficult to measure initially. Focusing first on verbalization of feelings provides a concrete and observable indicator of progress toward anxiety management.

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Correct Answer is A

Explanation

A. Keeping mucous membranes moist is an essential aspect of comfort care in palliative or hospice settings. Clients receiving end-of-life care often experience dry mouth, lips, and throat due to decreased oral intake, medications, or dehydration. Providing frequent oral care, offering ice chips, swabs, or water, and using lip balm can enhance comfort, prevent irritation, and support dignity. This is a priority teaching point for family caregivers.

B. Reporting changes in urine color is more relevant in acute or chronic disease management where interventions may alter renal function. In hospice care, the focus is on comfort rather than diagnostic monitoring, so this is less important than symptom relief.

C. Maintaining a high Fowler’s position may be helpful for clients with respiratory distress or aspiration risk, but it is not universally necessary for all hospice clients. Positioning should be individualized based on comfort and symptom management rather than strict adherence to one posture.

D. Recording daily weights is important in chronic disease management to monitor fluid status or nutrition, but in palliative care, the emphasis is on comfort and quality of life rather than tracking laboratory or weight trends. Daily weight monitoring is not a primary responsibility for family caregivers in hospice care.

A. Suggest that the UAP roll both of the gloves off and inside out at the same time. B. Instruct the UAP to use two pairs of gloves when fecal contamination is likely. C. Advise the UAP that the technique being used will result in hand contamination. D. Remind the UAP to discard the gloves in the biohazard container after removal.

Correct Answer is C

Explanation

A. Rolling both gloves off at the same time is not recommended, as it increases the risk of contamination. Proper glove removal involves peeling off one glove at a time, turning it inside out to avoid contact with contaminated surfaces.

B. Using two pairs of gloves (double-gloving) may be necessary for certain high-risk procedures, but it is not required for routine bedpan handling. The focus should be on proper technique rather than adding extra gloves unnecessarily.

C. Advising the UAP that the technique being used will result in hand contamination is correct. Sliding fingers inside the contaminated glove and rolling it off inappropriately can transfer pathogens to the skin. The nurse should correct the technique by teaching the proper method: grasp the outside of one glove at the wrist, peel it off inside out, then tuck it into the remaining glove and peel off the second glove inside out. This minimizes the risk of self-contamination and infection transmission.

D. Discarding gloves in the appropriate container is important, but the primary concern here is the incorrect removal technique, which poses an immediate contamination risk. Teaching correct removal takes priority over simply reminding where to discard gloves.

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The plan of care for a client who was recently diagnosed with breast cancer includes the nursing problem, "Anxiety related to the threat of death secondary to the cancer diagnosis." Which expected outcome should the nurse identify for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The hospice nurse is teaching the family of a client receiving palliative care at home on how to provide care. Which instruction should the nurse provide?

Correct Answer is A

Explanation

The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. Which action should the nurse implement?

Correct Answer is C

Explanation

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