Which patient should the nurse refer for hospice care?
a. 60-year-old with lymphoma whose children are unable to discuss issues related to dying
b. 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse
c. 28-year-old with AIDS-related dementia who needs palliative care and pain management
d. 56-year-old with advanced liver failure whose family members can no longer provide care in the home
ANS: C
Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients.
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Which of the following is the most appropriate nursing intervention to prevent development of postoperative paralytic ileus when caring for a postsurgical client?
A) Encourage progressive activity. B) Report large amounts of emesis. C) Encourage ambulation. D) Administer prescribed bulk-forming laxatives.
The nurse would expect which action immediately following the treatment of a cerebral spinal fluid leak in a post-spine-surgery client?
1. Keeping the client flat in bed for 2 hours 2. Raising the head of the bed (HOB) into a Trendelenburg position 3. Administering a bolus of IV fluids 4. Initiating strict isolation policies
When teaching a female client to perform breast self-examination, the nurse instructs the client to:
a. Press the pads of the fingers firmly to compress breast tissue against the rib cage. b. Lie in front of a mirror and observe for dimpling of the skin. c. Lift the fingers from the chest wall during palpation to better define the breast tissue. d. Apply gentle pressure to each breast while moving the fingers according to a designated pattern across the breast.