Nursing Elites

1. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

• A. Breathing ranging from very deep to very shallow with periods of apnea
• B. Shallow to normal breaths alternating with periods of apnea
• C. Rapid respirations that are unusually deep and regular
• D. An inability to breathe without dyspnea unless sitting upright

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

2. A client is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select ONE that does not apply)

• A. Find an activity that you enjoy and will keep your hands busy.
• B. Make a list of reasons you want to stop smoking.
• C. Identify a punishment for yourself in case you backslide.
• D. Drink at least eight glasses of water each day.

Correct answer: D

Rationale: When educating a client on smoking cessation, the nurse should include several strategies. Finding an activity to keep hands busy helps distract from smoking urges. Making a list of reasons to quit smoking reinforces motivation. Identifying a consequence for backsliding can serve as a deterrent. Drinking water is beneficial for overall health but is not directly related to smoking cessation. It's crucial to support the client, encourage healthy habits, and address challenges without punitive measures.

3. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

• A. Would you like information about advance directives?
• B. I will arrange for a psychiatrist to speak with you.
• C. Do you want to come off the transplant list?
• D. Would you like to speak with a priest or chaplain?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

4. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

• A. Hypoglycemia
• B. Hypertension
• C. Polyuria
• D. Oral candidiasis

Correct answer: D

Rationale: Fluticasone is a corticosteroid often used to manage asthma. One of the common adverse effects associated with inhaled corticosteroids like fluticasone is oral candidiasis, also known as thrush. This fungal infection can develop in the mouth and throat due to the steroid's local immunosuppressive effects. Patients should be advised to rinse their mouths after using inhaled corticosteroids to reduce the risk of oral candidiasis. Monitoring for symptoms such as white patches, sore throat, or difficulty swallowing is essential to detect and manage this adverse effect promptly.

5. A client who is interested in smoking cessation receives teaching from a nurse. Which statements should the nurse include in this teaching? (Select ONE that does not apply)

• A. Find an activity that you enjoy and that will keep your hands busy.
• B. Keep healthy snacks on hand to nibble on.
• C. Identify reasons for quitting smoking.
• D. Make a list of reasons for quitting smoking.

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should include advice to find an activity that keeps hands busy to help distract from smoking urges, keep healthy snacks on hand to manage oral cravings, and drink at least 8 glasses of water daily to aid in flushing out toxins. Making a list of reasons for quitting smoking is also beneficial to reinforce motivation. It is important to avoid punitive measures or punishments for relapses as this can negatively impact the client's progress.

Similar Questions