NUR401 Practice - Test Bank-Questions
and Answers All Correct and Verified.
Ch. 13
1. The nurse is caring for a terminally ill client who has 20-second periods of apnea followed by
periods of deep and rapid breathing. Which of the following terms should the nurse use to
document this finding?
a. Agonal breathing
b. Apneustic breathing
c. Death rattle respirations
d. Cheyne-Stokes respirations - Answer ANS: D
4. The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a
trip across the country "to settle some issues with my sisters and brothers." Which of the
responses should the nurse recognize that the client is manifesting?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of one's life - Answer ANS: C
5. The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client
about vacation plans for the next year. When the nurse asks about any concerns, the
spouse says, "I'm busy at work, but otherwise things are fine." Which of the following nursing
diagnoses is appropriate?
a. Ineffective denial related to the threat of unpleasant reality
b. Anxiety related to the threat to current status
c. Caregiver role strain related to inexperience with caregiving
d. Hopelessness related to chronic stress - Answer ANS: A
6. As the nurse admits a client with severe heart failure to the hospital, the client tells the nurse,
"If my heart or breathing stops, I do not want to be resuscitated." Which of the following
actions should the nurse take?
a. Ask if these wishes have been discussed with the health care provider.
b. Place a "do not resuscitate" (DNR) notation in the client's care plan.
c. Inform the client that a notarized advance directive must be included in the record
or resuscitation must be performed.
,d. Advise the client to designate a person to make health care decisions when the
client is not able to make them independently. - Answer ANS: A
7. A client who is very close to death is very restless and keeps repeating, "I am not ready to
die." Which of the following actions should the nurse take?
a. Remind the client that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the client needs.
c. Insist that family members remain at the bedside with the client.
d. Tell the client that everything possible is being done to delay death. - Answer ANS: B
8. The nurse is caring for a client in a hospice palliative care program who is experiencing
continuous, increasing amounts of pain. Which of the following time schedules should the nurse
implement for the administration of opioid pain medications?
a. Around-the-clock routine administration of analgesics
b. PRN doses of medication whenever the client requests
c. Enough pain medication to keep the client sedated and unaware of stimuli
d. Analgesic doses that provide pain control without decreasing respiratory rate - Answer ANS:
A
9. The nurse is caring for a client with lung cancer as part of a home hospice palliative program.
Which of the following interventions should the nurse implement?
a. Discuss cancer risk factors and appropriate lifestyle modifications.
b. Encourage the client to discuss past life events and their meaning.
c. Accomplish a thorough head-to-toe assessment once a week.
d. Educate the client about the purpose of chemotherapy and radiation. - Answer ANS: B
10. The nurse has been caring for a terminally ill client for the past 10 months. The nurse and
the
family are present when the client dies and feels saddened and tearful as the family members
begin to cry. Which of the following actions should the nurse take at this time?
a. Contact a grief counsellor as soon as possible.
b. Cry along with the client's family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since client losses are common. - Answer
ANS: B
,11. A client who is in the clinic for an immunization tells the nurse, "My mother died 4 months
ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every
day." Which of the following nursing diagnoses is most appropriate?
a. Ineffective role performance related to depression
b. Complicated grieving related to emotional disturbance (death of loved one)
c. Anxiety related to unmet needs (lack of knowledge about normal grieving)
d. Impaired mood regulation related to loneliness - Answer ANS: C
12. The family member of a client who is dying tells the nurse, "Mother doesn't respond any
more when I visit. I don't think she knows that I am here." Which of the following
responses by the nurse is most appropriate?
a. "You may need to cut back your visits for now to avoid overtiring your mother."
b. "Withdrawal may sometimes be a normal response when preparing to leave life."
c. "It will be important for you to stimulate your mother as she gets closer to dying."
d. "Many clients don't really know what is going on around them at the end of life." - Answer
ANS: B
13. Which of the following clients is most appropriate for the nurse to refer to hospice palliative
care?
a. A 60-year-old with lymphoma whose children are unable to discuss issues related
to dying
b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral
collapse
c. A 28-year-old with AIDS-related dementia who needs palliative care and pain
management
d. A 56-year-old with advanced liver failure whose family members can no longer
care for him or her at home - Answer ANS: C
14. A terminally ill client is admitted to the hospital. Which of the following actions should the
nurse include in the initial plan of care?
a. Determine the client's wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the client and family.
d. Encourage the client to talk about any fears or unresolved issues. - Answer ANS: A
15. The nurse is planning for an end-of-life care discussion with a newly admitted client who is
, terminally ill and has decided to use the NURSE protocol during the difficult conversation to
respond to client and/or family emotions. Which of the following terms describes the "E" in
the NURSE protocol?
a. Experimentation
b. Exploration
c. Empathy
d. Emotion - Answer ANS: B
C. 18
1. The nurse is preparing a client for a biopsy of a lump in the right breast and the client asks the
nurse about the difference between a benign tumour and a malignant tumour. Which of the
following responses by the nurse is correct?
a. "Benign tumours do not cause damage to other tissues."
b. "Benign tumours are likely to recur in the same location."
c. "Malignant tumours may spread to other tissues or organs."
d. "Malignant cells reproduce more rapidly than normal cells." - Answer ANS: C
The major difference between benign and malignant tumours is that malignant tumours invade
adjacent tissues and spread to distant tissues and benign tumours never metastasize. The other
statements are inaccurate. Both types of tumours may cause damage to adjacent tissues.
Malignant cells do not reproduce more rapidly than normal cells. Benign tumours do not
usually recur.
2. The nurse in the outpatient clinic is caring for a client who smokes heavily. To reduce the
client's risk of dying from lung cancer, which of the following actions will be best for the
nurse to take?
a. Educate the client about the seven warning signs of cancer.
b. Plan to monitor the client's carcinoembryonic antigen (CEA) level.
c. Discuss the risks associated with cigarettes during every client encounter.
d. Teach the client about the use of annual chest x-rays for lung cancer screening. - Answer
ANS: C
Education about the risks associated with cigarette smoking is recommended at every client
encounter, since cigarette smoking is associated with multiple health problems. A tumour
must be at least 0.5 cm large before it is detectable by current screening methods and may
already have metastasized by that time. Oncofetal antigens such as CEA may be used to
monitor therapy or detect tumour reoccurrence, but are not helpful in screening for cancer.
and Answers All Correct and Verified.
Ch. 13
1. The nurse is caring for a terminally ill client who has 20-second periods of apnea followed by
periods of deep and rapid breathing. Which of the following terms should the nurse use to
document this finding?
a. Agonal breathing
b. Apneustic breathing
c. Death rattle respirations
d. Cheyne-Stokes respirations - Answer ANS: D
4. The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a
trip across the country "to settle some issues with my sisters and brothers." Which of the
responses should the nurse recognize that the client is manifesting?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of one's life - Answer ANS: C
5. The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client
about vacation plans for the next year. When the nurse asks about any concerns, the
spouse says, "I'm busy at work, but otherwise things are fine." Which of the following nursing
diagnoses is appropriate?
a. Ineffective denial related to the threat of unpleasant reality
b. Anxiety related to the threat to current status
c. Caregiver role strain related to inexperience with caregiving
d. Hopelessness related to chronic stress - Answer ANS: A
6. As the nurse admits a client with severe heart failure to the hospital, the client tells the nurse,
"If my heart or breathing stops, I do not want to be resuscitated." Which of the following
actions should the nurse take?
a. Ask if these wishes have been discussed with the health care provider.
b. Place a "do not resuscitate" (DNR) notation in the client's care plan.
c. Inform the client that a notarized advance directive must be included in the record
or resuscitation must be performed.
,d. Advise the client to designate a person to make health care decisions when the
client is not able to make them independently. - Answer ANS: A
7. A client who is very close to death is very restless and keeps repeating, "I am not ready to
die." Which of the following actions should the nurse take?
a. Remind the client that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the client needs.
c. Insist that family members remain at the bedside with the client.
d. Tell the client that everything possible is being done to delay death. - Answer ANS: B
8. The nurse is caring for a client in a hospice palliative care program who is experiencing
continuous, increasing amounts of pain. Which of the following time schedules should the nurse
implement for the administration of opioid pain medications?
a. Around-the-clock routine administration of analgesics
b. PRN doses of medication whenever the client requests
c. Enough pain medication to keep the client sedated and unaware of stimuli
d. Analgesic doses that provide pain control without decreasing respiratory rate - Answer ANS:
A
9. The nurse is caring for a client with lung cancer as part of a home hospice palliative program.
Which of the following interventions should the nurse implement?
a. Discuss cancer risk factors and appropriate lifestyle modifications.
b. Encourage the client to discuss past life events and their meaning.
c. Accomplish a thorough head-to-toe assessment once a week.
d. Educate the client about the purpose of chemotherapy and radiation. - Answer ANS: B
10. The nurse has been caring for a terminally ill client for the past 10 months. The nurse and
the
family are present when the client dies and feels saddened and tearful as the family members
begin to cry. Which of the following actions should the nurse take at this time?
a. Contact a grief counsellor as soon as possible.
b. Cry along with the client's family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since client losses are common. - Answer
ANS: B
,11. A client who is in the clinic for an immunization tells the nurse, "My mother died 4 months
ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every
day." Which of the following nursing diagnoses is most appropriate?
a. Ineffective role performance related to depression
b. Complicated grieving related to emotional disturbance (death of loved one)
c. Anxiety related to unmet needs (lack of knowledge about normal grieving)
d. Impaired mood regulation related to loneliness - Answer ANS: C
12. The family member of a client who is dying tells the nurse, "Mother doesn't respond any
more when I visit. I don't think she knows that I am here." Which of the following
responses by the nurse is most appropriate?
a. "You may need to cut back your visits for now to avoid overtiring your mother."
b. "Withdrawal may sometimes be a normal response when preparing to leave life."
c. "It will be important for you to stimulate your mother as she gets closer to dying."
d. "Many clients don't really know what is going on around them at the end of life." - Answer
ANS: B
13. Which of the following clients is most appropriate for the nurse to refer to hospice palliative
care?
a. A 60-year-old with lymphoma whose children are unable to discuss issues related
to dying
b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral
collapse
c. A 28-year-old with AIDS-related dementia who needs palliative care and pain
management
d. A 56-year-old with advanced liver failure whose family members can no longer
care for him or her at home - Answer ANS: C
14. A terminally ill client is admitted to the hospital. Which of the following actions should the
nurse include in the initial plan of care?
a. Determine the client's wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the client and family.
d. Encourage the client to talk about any fears or unresolved issues. - Answer ANS: A
15. The nurse is planning for an end-of-life care discussion with a newly admitted client who is
, terminally ill and has decided to use the NURSE protocol during the difficult conversation to
respond to client and/or family emotions. Which of the following terms describes the "E" in
the NURSE protocol?
a. Experimentation
b. Exploration
c. Empathy
d. Emotion - Answer ANS: B
C. 18
1. The nurse is preparing a client for a biopsy of a lump in the right breast and the client asks the
nurse about the difference between a benign tumour and a malignant tumour. Which of the
following responses by the nurse is correct?
a. "Benign tumours do not cause damage to other tissues."
b. "Benign tumours are likely to recur in the same location."
c. "Malignant tumours may spread to other tissues or organs."
d. "Malignant cells reproduce more rapidly than normal cells." - Answer ANS: C
The major difference between benign and malignant tumours is that malignant tumours invade
adjacent tissues and spread to distant tissues and benign tumours never metastasize. The other
statements are inaccurate. Both types of tumours may cause damage to adjacent tissues.
Malignant cells do not reproduce more rapidly than normal cells. Benign tumours do not
usually recur.
2. The nurse in the outpatient clinic is caring for a client who smokes heavily. To reduce the
client's risk of dying from lung cancer, which of the following actions will be best for the
nurse to take?
a. Educate the client about the seven warning signs of cancer.
b. Plan to monitor the client's carcinoembryonic antigen (CEA) level.
c. Discuss the risks associated with cigarettes during every client encounter.
d. Teach the client about the use of annual chest x-rays for lung cancer screening. - Answer
ANS: C
Education about the risks associated with cigarette smoking is recommended at every client
encounter, since cigarette smoking is associated with multiple health problems. A tumour
must be at least 0.5 cm large before it is detectable by current screening methods and may
already have metastasized by that time. Oncofetal antigens such as CEA may be used to
monitor therapy or detect tumour reoccurrence, but are not helpful in screening for cancer.
