Samenvatting

30. A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the
following client statements should indicate to the nurse that the client is experiencing spiritual
distress?
A. “Life has its ups and downs”
-incorrect: This statement suggests the client is experiencing and incorporating a sense of
spiritual wellbeing by accepting life’s ups and downs.
B. “I believe that I control my own destiny”
-incorrect: This statement suggests the client is experiencing and incorporating a sense of
spiritual wellbeing by being in control of personal destiny.
C. “God is punishing me for something”
-Spiritual distress is an impaired ability to integrate meaning and purpose in life through various
means, including belief systems and relationships. Manifestations of spiritual distress can include
a feeling that a higher power is punishing the individual for some behavior.
D. “I like to keep my rosary beads in bed with me”
-incorrect: This statement suggests that the client is experiencing and incorporating a sense of
spiritual wellbeing by engaging in prayer activities such as the rosary.
31. While in the hospital, a client who has a terminal illness tells the nurse, “I can’t believe I’m
dying. A lot of bad people in the world are healthy and here I am dying!” Which of the following
responses should the nurse provide?
A. “Everyone dies sometimes; some die sooner than others.”
-incorrect: This is a nontherapeutic response that dismisses and minimizes the client’s feelings.
B. “Who do you think deserves to die more than you?”
-incorrect: This is a nontherapeutic response that could be perceived as confrontational by the
client.
C. “It does seem unfair, doesn’t it?”
-incorrect: While this response acknowledges the client’s feelings, it is a closed-ended statement
that does not facilitate further exploration of the client’s feelings.
D. “Tell me more about how you feel about dying?”
-This therapeutic response from the nurse seeks more information to form an accurate
assessment of the client’s feelings.
32. A nurse is administering medication to a client who asks the nurse to leave the medication at
the bedside to be taken at a later time. Which of the following responses should the nurse make?
A. “Call me when you are ready, and I will return with the medication.”
-The nurse is responsible for administering the medication and for following professional
standards by adhering to the 6 rights of medication administration.
B. “Since you were taking this mediation at home, I will leave it for you to take.”
-incorrect: At home, the client is responsible and accountable for actions regarding selfadministration of medications. In an inpatient setting, the nurse is responsible for administering
medication to the client.
C. “I will come back in 30 mins to check that you took the medication so I can chart the time.”
-incorrect: If the nurse returns to the client’s room in 30 minutes, the nurse will not be able to
verify that the client took the medication since the client could have hidden or discarded the
medication.
D. “If you refuse to take the medication now, I can’t give it again until your next scheduled
time.”
-incorrect: The nurse is responsible for administering the medication at the scheduled time.
Although the policy about time may vary by facility, a medication generally may be given within
1 hour of the prescribed time.
33. A nurse is admitting a client who will undergo a craniotomy. During the planning phase of
the nursing process, which of the following actions should the nurse take?
A. Establish client outcomes
-The planning phase of the nursing process includes developing goals and outcomes that help the
nurse create the client’s plan of care.
B. Collect information about past health problems
-incorrect: The nurse should collect information about the client’s past health problems during
the assessment phase of the nursing process.
C. Determine whether the client has met specific goals
-incorrect: The nurse should determine whether the client has met goals during the evaluation
phase of the nursing process.
D. Identify the client’s specific health problems
-incorrect: The nurse should identify the client’s specific health problems during the analysis
phase of the nursing process.
34. A nurse in a provider’s office is teaching a client about foods that are high in fiber. Which of
the following food choices made by the client indicate an understanding of the teaching? (SATA)
A. Canned peaches
-incorrect: Canned fruits, including peaches, are recommended for clients on a low-fiber diet.
Fresh fruits contain more fiber.
B. White rice
-incorrect: White rice is recommended for clients on a low-fiber diet. Brown rice is higher in
fiber.
C. Black beans
-Dried peas and beans, including black beans, are high in fiber.
D. Whole-grain bread
-Whole grains consist of the entire kernel and are also high in fiber.
E. Tomato juice
-incorrect: Canned juices, with the exception of prune juice, are recommended for clients on a
low-fiber diet.
35. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe
atelectasis. Which of the following acti

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