Exam 4 Ch. 42

23問 • 3年前

問題一覧

1. The hospice nurse is caring for a terminally ill patient. The patient’s son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient’s son currently?

b. Death anxiety related to feeling powerless over situation.

2. The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. The nurse identifies which term that best describes the activity of the patient’s children?

a. Anticipatory grieving

3. The nurse is caring for a female patient who died a few minutes previously. The patient’s family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse currently?

d. Offer to provide any needed supplies and provide privacy for the family.

4. The nurse is caring for an emergency room patient who died because of a mishap with a loaded gun. The patient’s body will be transported to the coroner’s office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital?

d. Necklace and watch

5. The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, “Quit crying. It’s not like you lost a real baby.” What term best describes the anguish felt by the patient?

a. Disenfranchised grief

6. A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient’s spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best?

b. “Anger is an expected part of the grieving process.”

7. The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse?

b. Be present but quiet and let the patient continue the conversation.

8. The nurse is caring for a patient who died a few minutes ago. The patient’s family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient’s body. What is the most appropriate action of the nurse?

d. Provide privacy and allow the patient’s family to grieve over the body.

9. The nurse is caring for a patient who lost her husband 1 year ago after 55 years of marriage. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the nursing diagnosis of dysfunctional grief applies to the patient. Which is the priority goal for the patient?

a. The patient will shower every other day and eat at least two meals a day.

10. The hospice nurse is caring for a several adult children shortly after the death of a parent. They have various reactions as they deal with their loss. The nurse recognizes which reactions to be in the cognitive domain?

c. They are easily distracted and often lose train of thought during conversation.

11. The hospice nurse is caring for a patient who is terminally ill. The patient’s spouse is the primary caregiver, providing constant care and spending all his or her time meeting the patient’s needs. The spouse says to the nurse “After my spouse dies, I will finally get that colonoscopy my provider has been bugging me about.” What does the nurse understand about this statement?

c. The spouse is making some realistic plans for life after the death.

12. The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient’s family arrives to see the patient’s body?

a. Gently wash the body and provide perineal care.

13. The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention by the nurse will be most appropriate to meet this patient’s wishes?

a. Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain.

14. The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action by the nurse?

d. Assist the patient to find the necessary information about endowed scholarships.

15. Which statement by the patient indicates to the nurse that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness?

b. “I want to spend what time I have left at home with my grandchildren.”

16. The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient’s daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse?

a. “Just let him know you are here, talk to him, and let him know that you love him.”

17. The nurse is caring for an Islamic patient who has just died. The family is traveling from overseas. Which action is the priority for the nurse to take right after the patient dies?

b. Rearrange the furniture so the bed can face Mecca

18. The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. The nurse knows which goal to be most appropriate for this patient?

d. The patient will use effective coping strategies with no alcohol consumption.

19. The nurse sees a young child in the clinic whose mother has only a few weeks to live. The child has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. The nurse identifies which stage of grieving that the patient is experiencing?

b. Anger

20. The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse?

b. “The focus right now needs to be on keeping your loved one comfortable.”

21. The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle crash in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse?

a. Check to make sure that the patient does not want to hurt or kill herself.

22. The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention?

c. Helping the patient to identify and complete desired tasks and activities

23. The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient’s family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse?

a. “Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea.”

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4