Final Exam Test Bank 100% PASSED
denial - ANS A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage
kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come
today, but I am not sure if I will need to come back again this week. I am feeling much better since my
discharge from the hospital and I think my kidneys are working again." The nurse should identify that
this client is demonstrating which of the following Kübler-Ross stages of grieving?
Breathing ranging from very deep to very shallow with periods of apnea - ANS A nurse is assessing the
respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following
assessment findings should the nurse identify as Cheyne-Stokes respirations?
i am hoping this will limit my discomfort - ANS A nurse is caring for a client who has cancer and is
receiving palliative care. Which of the following statements by the client indicates they understand this
type of treatment?
shoulders drop, facial muscles relax, pulse is within expected range - ANS A nurse provides a back
massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of
the following findings should the nurse identify as indicating a therapeutic response? (Select all that
apply.)
I just can't believe that this dialysis is going to ruin my whole life. - ANS A nurse is caring for a client who
has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse
identify as an indication of anticipatory grieving?
Discuss imitating hospice care with the client in a nursing home - ANS A nurse is caring for a client who
has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about
meeting the client's care needs at home. Which of the following actions should the nurse take?
"The doctor says I only have a few moments to live, but I know he is exaggerating to get me to take my
medication." - ANS A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following responses is an indication the client is in the denial phase of the grief process?
, Provide skin care with a moisture barrier cream. Administer artificial tears PRN. Perform mouth care
every hour. Administer oxygen 2 L/min via nasal cannula. - ANS A hospice nurse is reviewing the
prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the
nurse expect? (Select all that apply.)
low self esteem - ANS A nurse manager is discussing the differences between normal and maladaptive
grief with nursing staff. Which of the following findings should the nurse manager identify as being a
unique component of the maladaptive grieving process?
1) Make sure the provider has pronounced the client dead2) Verify the client's organ and tissue
donation status3) Remove medical equipment from the client4) Cleanse the body while adhering to the
body-fluid precautions5) Attach identification tags to the body - ANS A nurse is providing postmortem
care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on
the right, placing them in the order of performance. Use all the steps.)
Complete a neurological check (appropriate nursing intervention when a client displays sudden
confusion) - ANS A nurse on a medical unit is caring for a client who suddenly becomes confused and
drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and
temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?
Determine if the client uses hearing aids. - ANS A nurse is admitting a client who has a partial hearing
loss. Which of the following is the priority action by the nurse?
Removing the abdominal dressing - ANS A nurse is working with an assistive personnel (AP) while caring
for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for
completing?
Discontinue suction when assessing for peristalsis- Irrigate the NG tube with 0.9% sodium chloride
irrigation solution.- Place sequential compression devices on the bilateral lower extremities.- Reposition
the client form side to side every 2 hr. - ANS A nurse is caring for an older adult client who has had
surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following
interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)
denial - ANS A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage
kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come
today, but I am not sure if I will need to come back again this week. I am feeling much better since my
discharge from the hospital and I think my kidneys are working again." The nurse should identify that
this client is demonstrating which of the following Kübler-Ross stages of grieving?
Breathing ranging from very deep to very shallow with periods of apnea - ANS A nurse is assessing the
respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following
assessment findings should the nurse identify as Cheyne-Stokes respirations?
i am hoping this will limit my discomfort - ANS A nurse is caring for a client who has cancer and is
receiving palliative care. Which of the following statements by the client indicates they understand this
type of treatment?
shoulders drop, facial muscles relax, pulse is within expected range - ANS A nurse provides a back
massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of
the following findings should the nurse identify as indicating a therapeutic response? (Select all that
apply.)
I just can't believe that this dialysis is going to ruin my whole life. - ANS A nurse is caring for a client who
has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse
identify as an indication of anticipatory grieving?
Discuss imitating hospice care with the client in a nursing home - ANS A nurse is caring for a client who
has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about
meeting the client's care needs at home. Which of the following actions should the nurse take?
"The doctor says I only have a few moments to live, but I know he is exaggerating to get me to take my
medication." - ANS A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following responses is an indication the client is in the denial phase of the grief process?
, Provide skin care with a moisture barrier cream. Administer artificial tears PRN. Perform mouth care
every hour. Administer oxygen 2 L/min via nasal cannula. - ANS A hospice nurse is reviewing the
prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the
nurse expect? (Select all that apply.)
low self esteem - ANS A nurse manager is discussing the differences between normal and maladaptive
grief with nursing staff. Which of the following findings should the nurse manager identify as being a
unique component of the maladaptive grieving process?
1) Make sure the provider has pronounced the client dead2) Verify the client's organ and tissue
donation status3) Remove medical equipment from the client4) Cleanse the body while adhering to the
body-fluid precautions5) Attach identification tags to the body - ANS A nurse is providing postmortem
care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on
the right, placing them in the order of performance. Use all the steps.)
Complete a neurological check (appropriate nursing intervention when a client displays sudden
confusion) - ANS A nurse on a medical unit is caring for a client who suddenly becomes confused and
drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and
temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?
Determine if the client uses hearing aids. - ANS A nurse is admitting a client who has a partial hearing
loss. Which of the following is the priority action by the nurse?
Removing the abdominal dressing - ANS A nurse is working with an assistive personnel (AP) while caring
for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for
completing?
Discontinue suction when assessing for peristalsis- Irrigate the NG tube with 0.9% sodium chloride
irrigation solution.- Place sequential compression devices on the bilateral lower extremities.- Reposition
the client form side to side every 2 hr. - ANS A nurse is caring for an older adult client who has had
surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following
interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)
