NR-226 Patient Care Fundamentals - Set 5 - Part 3

Correct Answer: Those are healthy ways to carry this loss.

The death of a spouse cannot be changed, so emotion-focused strategies fit the situation. Crying, spiritual practice and a support group regulate distress and are appropriate coping, and the nurse's role is to affirm and enable them. Option a is incorrect because problem-focused planning fits stressors the person can change, and nothing about a death can be solved. Pushing an action plan here misreads the situation and can feel dismissive. Option b is incorrect because tears are an ordinary and useful release rather than an obstacle. Labeling her grief as an impediment judges a normal response and is likely to end the conversation. Option d is incorrect because telling a client what she should do removes her autonomy and substitutes the nurse's judgment for hers. Distraction offered as advice also sidesteps the grief she is already working through.

Correct Answer: Assist the client to the commode after breakfast

Mass movements cluster twenty to forty minutes after a meal, so toileting the client on a commode shortly after breakfast uses the gastrocolic reflex. Assisting to the commode is within the assistive personnel's scope. Option a is incorrect because waiting for a request abandons the scheduled timing that makes bowel training work. A bedpan is also less physiological than a commode, since the client cannot sit upright with supported feet. Option c is incorrect because restricting fluid is the opposite of what a constipated bowel needs. Less water in the gut means the colon reclaims more from the stool, hardening it and defeating the whole programme. Option d is incorrect because inserting a rectal suppository is a medication administration the nurse performs rather than delegates. Assistive personnel may position and assist the client, but they do not give drugs by any route.

Correct Answer: Left lateral Sims position with right knee flexed

The descending and sigmoid colon lie on the left side, so the left lateral Sims position lets gravity carry the solution along the natural curve of the bowel and improves retention and effectiveness. Option b is incorrect because sitting upright lets the solution run straight back out before it can distend the bowel, and the tube can injure the rectal wall when the bowel curve cannot be followed. Option c is incorrect because lying on the right side sends the solution away from the segment it needs to fill. It is a fallback only when a left-sided position is impossible, and the result is poorer. Option d is incorrect because a supine client has no side-lying slope for the fluid to follow, so the solution pools in the rectum and is expelled early. Flexed knees alone do not solve that.

Correct Answer: Remain with the client and summon help

A client expressing hopelessness must never be left alone. Remaining at the bedside preserves safety while the nurse uses the call system to bring a colleague, who can then notify the provider and mental health team. Option a is incorrect because paging the provider is necessary but requires the nurse to leave the room. Escalation happens after help is summoned to the bedside, not by abandoning a client in acute distress. Option b is incorrect because recording the exact words matters for the record and the handoff, yet it does nothing about the danger in the room right now. Charting never comes before safety. Option c is incorrect because family can be a valuable support later, but contacting them delays professional evaluation and still leaves the client unattended. Mobilizing support follows stabilization rather than replacing it.

Correct Answer: Stay with her and arrange immediate help

Statements about wanting to join the deceased are taken literally and treated as a safety event. The nurse stays with the client, keeps her safe, and summons the provider and crisis resources without leaving her alone. Option a is incorrect because leaving the house puts distance between the nurse and a client who has just disclosed risk. The call still needs to be made, but it is made without abandoning her. Option c is incorrect because false reassurance dismisses what she has just risked saying and closes the subject. Predicting that the feeling will pass gives her no protection tonight and no reason to disclose again. Option d is incorrect because a visit tomorrow leaves tonight uncovered. Risk disclosed now requires action now, and postponing the response converts an urgent safety problem into an appointment on a calendar.

Correct Answer: The client with an ileostomy

An ileostomy discharges effluent before the colon can reclaim water and sodium, so the entire absorptive length of the large bowel is bypassed. Output is continuous and liquid, making dehydration and electrolyte loss the standing risk. Option a is incorrect because a sigmoid stoma sits at the very end of the colon, past every segment that reabsorbs water. Its output is formed and its fluid risk is the lowest of any diversion. Option b is incorrect because most of the colon still lies upstream of a descending stoma, leaving stool semi-formed to formed. Fluid and sodium have already been reclaimed by the time output reaches that point. Option d is incorrect because output from the transverse colon is mushy and semi-formed, a moderate rather than a maximal loss. Ranking it first would skip past the diversion that bypasses the colon altogether.

Correct Answer: The bowel is structurally normal despite real symptoms

This picture is irritable bowel syndrome, a functional disorder in which motility and visceral sensitivity are disturbed but the bowel wall is intact. Validating that the pain is real while explaining normal results is the nurse's task. Option b is incorrect because tissue destruction belongs to inflammatory bowel disease, which shows ulceration on endoscopy and raises C-reactive protein and faecal calprotectin. Both results came back normal in this client. Option c is incorrect because a functional disorder carries no added malignancy risk. It is long-standing colitis, with years of inflamed epithelium, that raises the chance of cancer and calls for surveillance. Option d is incorrect because periodic surveillance colonoscopy is the rule for someone diagnosed with inflammatory bowel disease, beginning years after that diagnosis. Scheduling it here would expose the client to repeated procedures without benefit.

Correct Answer: Moisten the mouth with soft swabs

Moistening the mouth is routine comfort care with a predictable outcome, well within the assistive role. Mouth care relieves the thirst of a dying client more effectively than intravenous fluid does. Option a is incorrect because teaching a family what dying will look like requires assessment of what they already understand and readiness to answer hard questions. Teaching cannot be handed to unlicensed staff. Option b is incorrect because adjusting an analgesic dose is medication administration combined with clinical judgment about effect. Both sit squarely inside the licensed nurse's scope and neither transfers to assistive personnel. Option c is incorrect because stopping a therapy is a decision made by the nurse and provider after weighing whether it still relieves the client's breathlessness. Delegating that judgment would place an unlicensed worker in a clinical decision.

Correct Answer: J. William Worden and his tasks

Worden's third task is adjusting to a world without the deceased, which includes the external adjustments of who pays the bills and who drives. Mourning in his model is active work. Option a is incorrect because Parkes contributed an empirically studied sequence of phases drawn from bereaved widows, not a set of assignments the mourner carries out. Phases describe what happens rather than what to do. Option c is incorrect because Stroebe and Schut authored the dual process model, whose signature idea is oscillation between confronting the loss and taking a break from it. They did not describe mourning tasks. Option d is incorrect because Kubler-Ross listed five emotional responses observed in dying patients, ending with acceptance. Her model offers no assignment the mourner completes and was not built from the bereaved.

Correct Answer: Notify the provider of his current wishes

A client with capacity may change or revoke a directive at any time, and the current expressed wish overrides the written document. The nurse notifies the provider so orders and paperwork are updated. Option a is incorrect because a living will speaks only for a client who has lost capacity. This client is alert and oriented, so his own voice is the authority and the paper yields to it. Option b is incorrect because surrogate decision making begins only when the client cannot decide. Handing the choice to the daughter while her father is speaking clearly for himself strips him of his own autonomy. Option d is incorrect because ethics consultation is reserved for genuine conflicts about the right course. Nothing here is ambiguous, and calling a committee delays the order change this client needs before he deteriorates.