The nurse identifies actions that might assist the family of the terminally ill client, including: Standard Text: Select all that apply
1. Suggesting placement in a hospice unit instead of home care.
2. Allowing family to visit ad lib.
3. Reinforcing information that family members might not have absorbed.
4. Reorienting the client who is hallucinating.
5. Asking direct questions about needs.
2,3,4,5
Rationale: Client and family wishes regarding hospice care need to be respected.
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The parent of a child receiving the H. influenzae type b (Hib) vaccine asks about the potential development of serious adverse effects. The nurse should inform the parent that
a. meningitis is a common side effect. b. serious side effects have not been reported for this vaccine. c. headache and seizures are the most common side effects. d. all of the potential side effects of other vaccines are expected with the Hib vac-cine.
What question is most important for the nurse to ask the family members of the client with herpes zoster?
A. "Have you ever had measles?" B. "Have you ever had mumps?" C. "Have you ever had chickenpox?" D. "Were you vaccinated against polio?"
The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock?
1. Septic 2. Cardiogenic 3. Anaphylactic 4. Neurogenic
Which nursing actions help prevent infection when placing ointments into a patient's eye? (Select all that apply.)
a. Having the patient remove contact lenses b. Avoiding touching the tip of the applicator c. Using separate drug tubes for the right and the left eye d. Applying pressure over the punctum for 1 minute after instilling the drug e. Waiting 10 minutes between the administration of more than one type of eye drug f. Squeezing out and discarding a small amount of ointment before instilling the drug