Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
A. Contact the facility chaplain to visit with the client.
Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.
B. Explain the process of leaving the facility against medical advice.
Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.
C. Make a referral for social services.
Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.
D. Encourage the client to continue with inpatient care.
Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.
- B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.
- C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.
- D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.
Similar Questions
A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?
A. Instruct the client about the importance of regular medical appointments.
Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.
B. Encourage the client to participate in daily exercise.
Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.
C. Explain proper foot care techniques to the client.
Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.
D. Ensure that the client understands the medication regimen.
Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.
Full Explanation
- A. Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.
- B. Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.
- C. Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.
- D. Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.
A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
A. "We can expect the hospice nurse to provide support for us after our mother's death."
"We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.
B. "A hospice nurse will come to the house each time our mother needs pain medication."
"A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.
C. "Now that my mother is receiving hospice services, we will not be able to get respite care."
"Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.
D. "Hospice care focuses on arranging treatment that will prolong our mother's life."
"Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.
Full Explanation
- A. "We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.
- B. "A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.
- C. "Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.
- D. "Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.
A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and
drainage for cellulitis on the left arm. Which of the following techniques should the nurse use?
A. Plan for a 30-min instructional session.
Plan for a 30-min instructional session: Preschool-age children have limited atention spans and may become restless or disinterested during a 30-minute instructional session. Shorter, more focused teaching sessions are generally more effective for this age group.
B. Schedule the instructional session for 24 to 36 hr before the procedure
Schedule the instructional session for 24 to 36 hr before the procedure: Scheduling the instructional session too far in advance may result in the child forgetting or not retaining the information. It is recommended to conduct the teaching session closer to the procedure date to ensure the information is fresh in the child's mind.
C. Take the child on a tour of the surgery and recovery areas.
Take the child on a tour of the surgery and recovery areas: While taking a child on a tour of the surgery and recovery areas can be beneficial for older children or adolescents, it may not be suitable or developmentally appropriate for a preschooler. Young children may find the hospital environment overwhelming or intimidating, and the tour may increase their anxiety or fear. Using a more hands-on and interactive approach, such as helping the child put a dressing on a doll, is typically more effective for preschool-age children.
D. Help the child put a dressing on a doll.
The nurse should use the technique of helping the child put a dressing on a doll to reinforce teaching for a preschooler who is about to undergo an incision and drainage for cellulitis. This technique allows the child to participate in a hands-on activity that simulates the upcoming procedure and helps them become familiar with the process in a non-threatening and interactive manner. It provides an opportunity for the child to ask questions, express concerns, and gain a sense of control and understanding about what will happen during their own procedure.