Question : A client who is in the clinic for an immunization tells the nurse : 2135501
11. A client who is in the clinic for an immunization tells the nurse, “My mother died 4 months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think about her every day.” Which of the following nursing diagnoses is most appropriate?
a. Ineffective role performance related to depression
b. Complicated grieving related to emotional disturbance (death of loved one)
c. Anxiety related to unmet needs (lack of knowledge about normal grieving)
d. Impaired mood regulation related to loneliness
12. The family member of a client who is dying tells the nurse, “Mother doesn’t really respond any more when I visit. I don’t think she knows that I am here.” Which of the following responses by the nurse is most appropriate?
a. “You may need to cut back your visits for now to avoid overtiring your mother.”
b. “Withdrawal may sometimes be a normal response when preparing to leave life.”
c. “It will be important for you to stimulate your mother as she gets closer to dying.”
d. “Many clients don’t really know what is going on around them at the end of life.”
13. Which of the following clients is most appropriate for the nurse to refer to hospice palliative care?
a. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying
b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse
c. A 28-year-old with AIDS-related dementia who needs palliative care and pain management
d. A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home
14. A terminally ill client is admitted to the hospital. Which of the following actions should the nurse include in the initial plan of care?
a. Determine the client’s wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the client and family.
d. Encourage the client to talk about any fears or unresolved issues.
15. The nurse is planning for an end-of-life care discussion with a newly admitted client who is terminally ill and has decided to use the NURSE protocol during the difficult conversation to respond to client and/or family emotions. Which of the following terms describes the “E” in the NURSE protocol?
a. Experimentation
b. Exploration
c. Empathy
d. Emotion
