NCLEX - BASIC CARE AND COMFORT Day1 (Part 2)

Family of dying client concerned about dehydration. They ask for IV fluids. Nurse's response should be based on:

• Artificial hydration makes clients more comfortable
• Decisions should align with client preferences and goals
• HCP prescribes fluids when client can’t swallow
• Withholding fluids speeds up dying
• -

Answer explanation

The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life. (Option 1) Artificial hydration does not seem to help dying clients feel more comfortable, and IV fluids could cause distressful symptoms (Option 3) The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration. dying clients who do not receive artificial hydration live just as long as those who do receive IV fluids.

Client newly prescribed crutches. What finding shows need for more teaching?

• Torn axillary pads
• Elbows bent 30°
• Crutches and injured foot moved together in 3-point gait
• 3 finger-width space between axilla and pad
• -

Answer explanation

The proper fit and use of crutches are important in preventing injury. They include: (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating

Executive client newly diagnosed with hypertension. Most effective teaching strategy?

• Leave diet pamphlets
• Refer to nurse case manager
• Sit with client during meal selection
• Turn on education channel
• -

Answer explanation

When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner's: Need to know Readiness to learn Prior experiences Motivation to learn Orientation to learning Self-concept Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating. with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information. (Option 1) Pamphlets will be helpful to reinforce the teaching that the nurse has already done in the hospital with the client directly. (Option 2) The primary nurse or the nurse case manager can refer the client to be seen by a dietician before leaving the hospital or to follow up with one when discharged. This will be helpful to the client, but the opportunity to teach when the information is immediately applicable is preferred. (Option 4) The hospital education channel is a good source of information for the client, but it does not actively involve the client in the teaching.

GN caring for stroke clients. Which statements show correct understanding?

• Approach visual impairment from affected side
• Dress affected side first
• Use written instructions for receptive aphasia
• Teach scanning for left-sided neglect
• Expect impulsive behaviors with right-sided stroke

Answer explanation

Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should first clothe the affected side, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance (Option 2). Unilateral neglect is an alteration in sensory perception that causes plate). Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side (Option 4). Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect (Option 1) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client (Option 3) Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication.

Nurse providing end-of-life care. Spouse asks, “Will you stay with us?”

• I can come back at the end of my shift…” I will ask a friend or family member…”
• I can stay and sit with you for a short time…” I’ll contact the chaplain…”
• I will ask a friend or family member…
• I can stay and sit with you for a short time…
• I’ll contact the chaplain…

Answer explanation

During the end-of-life process, the clients' family members may be frightened, sad, confused, or concerned, and they may ask the nurse questions about belief systems or the death process. At times, clients or family members may simply want the nurse to sit with them and provide reassurance that their loved one is worthy of time and attention. In the given situation, the most therapeutic response by the support. This is not the best response. (Option 2) Ignoring the request by offering to ask a family member or friend to stay with the spouse is nontherapeutic and invalidates the spouse's needs. (Option 4) Although contacting the chaplain may be appropriate, this response does not answer the spouse's request that the nurse stay with the spouse.

Nurse speaking to client with advanced Alzheimer disease. Which techniques are appropriate?

• Ask open-ended questions
• Face the client while speaking
• Speak in a loud voice
• Turn off the television and close the door
• Use simple statements and questions

Answer explanation

Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals way for the nurse to obtain information and communicate is to use simple statements and questions (Option 5). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option 2). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option 4). (Option 1) Asking open-ended questions is a valuable communication technique for collecting information from most clients, but it may confuse the client with AD. The nurse should instead ask simple, direct questions. and confusion.