Fundamentals Of Nursing NCLEX Quiz 23

1. What are the stages of dying according to Elizabeth Kubler-Ross?

Numbing; yearning and searching; disorganization and despair; and reorganization.

Anticipatory grief. perceived loss. actual loss. and renewal.

Denial. anger. bargaining. depression. and acceptance.

The stages of dying according to Elizabeth Kubler-Ross are denial, anger, bargaining, depression, and acceptance.

Explanation

The stages of dying according to Elizabeth Kubler-Ross are denial, anger, bargaining, depression, and acceptance.

2. A client is hospitalized in the end stage of terminal cancer. His family members are sitting at his bedside. What can the nurse do to best aid the family at this time?

Limit the time visitors may stay so they do not become overwhelmed by the situation.

Avoid telling family members about the client’s actual condition so they will not lose hope.

Discourage spiritual practices because this will have little connection to the client at this time.

Find simple and appropriate care activities for the family to perform.

It is helpful for the nurse to find simple care activities for the family to perform. such as feeding the client. washing the client’s face. combing hair. and filling out the client’s menu. This helps the family demonstrate their caring for the client and enables the client to feel their closeness and concern. a. Older adults often become particularly lonely at night and may feel more secure if a family member stays at the bedside during the night. The nurse should allow visitors to remain with dying clients at any time if the client wants them. It is up to the family to determine if they are feeling overwhelmed. not the nurse.

Explanation

It is helpful for the nurse to find simple care activities for the family to perform. such as feeding the client. washing the client’s face. combing hair. and filling out the client’s menu. This helps the family demonstrate their caring for the client and enables the client to feel their closeness and concern. a. Older adults often become particularly lonely at night and may feel more secure if a family member stays at the bedside during the night. The nurse should allow visitors to remain with dying clients at any time if the client wants them. It is up to the family to determine if they are feeling overwhelmed. not the nurse.

3. A client has recently been told he has terminal cancer. As the nurse enters the room. he yells. "My eggs are cold. and I'm tired of having my sleep interrupted by noisy nurses!" The nurse may interpret the client's behavior as:

An expression of the anger stage of dying

An expression of disenfranchised grief

The result of maturational loss

The result of previous losses

In the anger stage of Kubler-Ross’s stages of dying. the individual resists the loss and may strike out at everyone and everything. in this case. the nurse.

Explanation

In the anger stage of Kubler-Ross’s stages of dying. the individual resists the loss and may strike out at everyone and everything. in this case. the nurse.

4. A client who had a "Do Not Resuscitate" order passed away. After verifying there is no pulse or respirations. the nurse should next:

Have family members say goodbye to the deceased.

Call the transplant team to retrieve vital organs.

Remove all tubes and equipment (unless organ donation is to take place). clean the body. and position appropriately.

Call the funeral director to come and get the body.

The body of the deceased should be prepared before the family comes into view and say their goodbyes. This includes removing all equipment. tubes. supplies. and dirty linens according to protocol. bathing the client. applying clean sheets. and removing trash from the room.

Explanation

The body of the deceased should be prepared before the family comes into view and say their goodbyes. This includes removing all equipment. tubes. supplies. and dirty linens according to protocol. bathing the client. applying clean sheets. and removing trash from the room.

5. Most litigation in the hospital comes from the:

Nurse abandoning the clients when going to lunch

Nurse following an order that is incomplete or incorrect

Nurse documenting blame on the physician when a mistake is made

Supervisor watching a new employee check his or her skills level

The nurse is responsible for clarifying all orders that are illegible. unreasonable. unsafe. or incorrect. The failure of the nurse to question the physician about an order creates an area of liability on the nurse’s part because this is perceived as a medical action and not the role of the nurse to write orders. Some RNs do have prescriptive privileges based upon advanced degrees and certification. Therefore the nurse who cannot correct the order must document that the physician was called and clarification or a new order was given to correct the unclear or illegible one that was currently on the chart. Phone calls. follow-up. and lack of follow-up by the physician should also be documented if there is a problem with getting the information in a timely manner. The nurse must show the sequence of events of a situation in a clear manner if there is any conflict or question about any orders or procedures that were not appropriate. Assessments and documentation of the client’s status should also be included if there is a potential risk for harm present. Contact of the staff’s chain of command should also be specifically stated for the proof of the responsibilities being followed according to hospital policy.

Explanation

The nurse is responsible for clarifying all orders that are illegible. unreasonable. unsafe. or incorrect. The failure of the nurse to question the physician about an order creates an area of liability on the nurse’s part because this is perceived as a medical action and not the role of the nurse to write orders. Some RNs do have prescriptive privileges based upon advanced degrees and certification. Therefore the nurse who cannot correct the order must document that the physician was called and clarification or a new order was given to correct the unclear or illegible one that was currently on the chart. Phone calls. follow-up. and lack of follow-up by the physician should also be documented if there is a problem with getting the information in a timely manner. The nurse must show the sequence of events of a situation in a clear manner if there is any conflict or question about any orders or procedures that were not appropriate. Assessments and documentation of the client’s status should also be included if there is a potential risk for harm present. Contact of the staff’s chain of command should also be specifically stated for the proof of the responsibilities being followed according to hospital policy.

6. When helping a person through grief work. the nurse knows:

Coping mechanisms that were effective in the past are often disregarded in response to the pain of a loss

A person’s perception of a loss has little to do with the grieving process.

The sequencing of stages of grief may occur in order. they may be skipped. or they may recur.

Most clients want to be left alone.

Grief is manifested in a variety of ways that are unique to an individual and based on personal experiences. cultural expectations. and spiritual beliefs. The sequencing of stages or behaviors of grief may occur in order. they may be skipped. or they may recur. The amount of time to resolve grief also varies among individuals.

Explanation

Grief is manifested in a variety of ways that are unique to an individual and based on personal experiences. cultural expectations. and spiritual beliefs. The sequencing of stages or behaviors of grief may occur in order. they may be skipped. or they may recur. The amount of time to resolve grief also varies among individuals.

7. When caring for a terminally ill client. it is important for the nurse maintain the client's dignity. This can be facilitated by:

Spending time to let clients share their life experiences

Decreasing emphasis on attending to the client’s appearance because it only increases their fatigue

Making decisions for clients so they do not have to make them

Placing the client in a private room to provide privacy at all times

A. Spending time to let clients share their life experiences enables the nurse to know clients better. Knowing clients then facilitates choice of therapies that promote client decision making and autonomy. thus promoting a client’s self-esteem and dignity.

Explanation

A. Spending time to let clients share their life experiences enables the nurse to know clients better. Knowing clients then facilitates choice of therapies that promote client decision making and autonomy. thus promoting a client’s self-esteem and dignity.

8. Which statement is correct?

Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD).

A second trimester abortion can be given without state involvement.

Student nurses cannot be sued for malpractice while in a nursing clinical class.

Anyone. at any age. can be treated without parental permission for an STD infection. The client is “advised” to contact sexual partners but is not “required” to give names. Permission from parents is not needed. based upon current privacy laws.

Explanation

Anyone. at any age. can be treated without parental permission for an STD infection. The client is “advised” to contact sexual partners but is not “required” to give names. Permission from parents is not needed. based upon current privacy laws.

9. The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?

Reflex vasoconstriction occurs.

Reflex vasodilation occurs.

Systemic response occurs.

Local response occurs.

If heat is applied for 1 hour or more. blood flow is reduced by reflex vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application

Explanation

If heat is applied for 1 hour or more. blood flow is reduced by reflex vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application

10. Bereavement may be defined as:

The emotional response to loss.

The outward. social expression of loss.

Postponing the awareness of the reality of the loss.

The inner feeling and outward reactions of the survivor.

Bereavement is the experience of losing someone or something significant, and it encompasses both the inner emotional state and the outward expressions of grief. It involves not only the internal feelings of sadness, pain, and longing but also the external reactions such as crying, withdrawal, or anger. This answer captures the comprehensive nature of bereavement, highlighting that it involves both the inner and outer aspects of the survivor's experience.

Explanation

Bereavement is the experience of losing someone or something significant, and it encompasses both the inner emotional state and the outward expressions of grief. It involves not only the internal feelings of sadness, pain, and longing but also the external reactions such as crying, withdrawal, or anger. This answer captures the comprehensive nature of bereavement, highlighting that it involves both the inner and outer aspects of the survivor's experience.