HESI Evolve Brain Attack (Stroke)

Points Awarded31.00Points Missed0.00Percentage100%Clinical ManifestationsThe Emergency Department (ED) nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. 1.Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (Select all that apply.)A) A carotid bruit.CORRECTThe carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.  B) Elevated blood pressure.CORRECTWhen a client has a brain attack (stroke), the blood pressure will often respond by going up. Increased BP is a sign of increased intracranial pressure.C) Hyperreflexic deep tendon reflexes.INCORRECTInitially, flaccid paralysis occurs, resulting in hyporeflexic deep tendon reflexes.D) Decreased bowel sounds.INCORRECTThe bowel sounds are not indicative of a brain attack.E) Difficulty swallowing.CORRECTDifficulty swallowing can accompany a brain attack (stroke), placing the client at risk for aspiration.The ED physician has completed an assessment. Gail is sitting at the bedside while the ED nurse continues to assess Nancy every 15 minutes.2.Which assessment finding warrants immediate intervention by the nurse?A) Nancy’s Glasgow Coma Scale (GCS) score increases.INCORRECTA decreasing, not increasing, GCS indicates worsening of the client's condition. This finding does not warrant immediate intervention by the nurse.B) Nancy’s bilateral grip strength is unequal.INCORRECTThis is an expected finding in a client with a brain attack. This finding does not warrant immediate intervention by the nurse.C) Nancy only responds to painful stimuli.CORRECTThis decrease in responsiveness warrants immediate intervention by the nurse, indicating a worsening condition (increased intracranial pressure).D) Nancy has a negative Babinski's reflex bilaterally.INCORRECTA negative Babinski's reflex is expected in a client with an intact brain stem. This finding does not warrant immediate intervention by the nurse.Due to her deteriorating condition, Nancy is immediately referred to the neurologist. The ED nurse realizes that Nancy has probably suffered a left-sided brain attack.3.Which clinical manifestation further supports this assessment?A) Visual field deficit on the left side.INCORRECTThese deficits usually occur with right-sided brain attack.B) Spatial-perceptual deficits.INCORRECTThese deficits usually occur with right-sided brain attack.C) Paresthesia of the left side.INCORRECTThese deficits usually occur with right-sided brain attack.D) Global aphasia.CORRECTGlobal aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere.  Diagnostic TestsThe neurologist writes a diagnosis of, "Suspected brain attack" and prescribes a noncontrast computed tomography (CT) scan STAT.4.Which nursing intervention should the nurse implement when preparing Nancy and her daughter for this procedure?A) Determine if the client has any allergies to iodine.INCORRECTThis information is important if contrast dye is being used for the CT scan.B) Explain to the daughter that her mother will have to remain still throughout the CT scan.CORRECTBecause head motion will distort the images, Nancy will have to remain still throughout the procedure. Since Nancy has a decreased LOC, she may require head support to accomplish this.C) Premedicate the client to decrease pain prior to having the procedure.INCORRECTCT scanning is a noninvasive and painless procedure.D) Provide an explanation of relaxation exercises prior to the procedure.INCORRECTWhile this is a worthwhile intervention to decrease anxiety for an alert client, Nancy’s LOC would not support this intervention. In addition, there is another intervention that is a priority. Continued support of Nancy’s daughter would be appropriate.The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT.5.Which data warrants immediate intervention by the nurse concerning this diagnostic test?A) Elevated blood pressure.INCORRECTThis would not affect the MRI.B) Allergy to shell fish.INCORRECTThis would not affect the MRI.C) Right hip replacement.CORRECTThe magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.D) History of atrial fibrillation.INCORRECTThis would not affect the MRI.Therapeutic CommunicationNancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her mother's bed. The nurse asks Gail if there is anyone that can be called so she won't be alone. She informs the nurse that she is an only child and her father died years ago. Gail states, "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?"6.Which response is best by the nurse?A) "I am sorry, but what happened to your mother is confidential and I cannot give you any information."INCORRECTThe nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions.B) "Your mother has had a stroke, and the blood supply to the brain has been compromised."CORRECTThe nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.C) "How do you feel about what the healthcare provider said?"INCORRECTThe nurse should give facts first and then address her feelings after the information is provided.D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."INCORRECTThe nurse can, and should, address Gail's lack of knowledge.Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have."7.How should the nurse respond?A) "I am sure everything will be all right."INCORRECTThis response provides false reassurance and does not allow Gail to share her feelings.B) "I know this is scary for you. Would you like to sit and talk?"CORRECTThis therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take time to discuss the situation. C) "I will notify the chaplain to come and sit with you so you won't be alone."INCORRECTThis is passing the buck. The nurse should address Gail's feelings.D) "I am sure your mother knows you are here. Just keep talking to her."INCORRECTThis may be therapeutic for Nancy, but it is not therapeutic for Gail.Nursing InterventionsThe neurologist diagnoses an ischemic left-sided brain attack (stroke). The neurologist determines that Nancy is not a candidate for tissue plasminogen activator (tPA). Enoxaparin (Lovenox) 1 mg/kg subcutaneously every 12 hours is prescribed.8.Nancy weighs 145 pounds. How many mg of enoxaparin (Lovenox) will the nurse administer in each dose? (Enter the numerical value only. If rounding is required, round to the whole number). 66CORRECT145 pounds divided by 2.2 kg =65.9 kg. 65.9 kg. X 1 mg/kg = 65.9 mg = 66 mg9.With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in Nancy's plan of care?A) Monitor INR daily.INCORRECTThe nurse should monitor the PTT level during heparin therapy. INR is monitored for warfarin (Coumadin) therapy.B) Assess neurological status every shift.INCORRECTThe neurological status must be monitored more frequently than every 8 or 12 hours as indicated by the shift change.C) Evaluate platelet levels daily.INCORRECTAnticoagulants inhibit thrombin formation and do not usually affect platelet levels.D) Keep the head of the bed elevated.CORRECTMaintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing the airway.The nurse continues to monitor Nancy's condition closely.10.Which finding would require immediate intervention by the nurse?A) Nancy's cardiac output is less than 4 L/min.CORRECTThe normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.B) Nancy's pulse oximeter reading is greater than 95%.INCORRECTA pulse oximeter reading of 95% indicates adequate oxygenation to the peripheral tissues.C) Nancy's serum potassium level is 3.9 mEq/L.INCORRECTThis potassium level is within normal limits (3.5-5.5 mEq/L).D) Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions.INCORRECTOccasional PVCs do not require immediate intervention.Though Nancy's SaO2, potassium level, and telemetry readings are within normal limits for her age, her cardiac output is low.As the nurse assesses Nancy, Gail asks, "Why isn't my mother a candidate for thrombolytic therapy?"11.Which nursing intervention(s) would be priority at this time? (Select all that apply.)A) Monitor level of consciousness.CORRECTWith a decreased cardiac output, cerebral perfusion will be affected. This can be reflected in a further decreased level of consciousness.B) Monitor vital signs every shift.INCORRECTWith a decreased cardiac output, vital signs should be monitored more frequently for signs of shock. Prescribed protocol may even be every 1-2 hours.C) Strict intake and output.CORRECTThe kidneys use 25% of cardiac output, so when cardiac output is decreased, the kidneys may start failing. Close monitoring is essential.D) Monitor capillary refill every 2-4 hours.CORRECTDecreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than 3 seconds.E) Contact physician.CORRECTThe physician needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluids if hypovolemia is an issue and to determine other medical interventions.12.How should the nurse respond?A) "I think that is something you should discuss with your mother’s healthcare provider."INCORRECTThe nurse has the knowledge and ability to answer the question.B) "She is not a candidate because of therapeutic time constraints related to this medication."CORRECTThrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. Nancy had symptoms for 24 hours before being brought to the medical center. C) "tPA is usually not administered to anyone older than 65 years."INCORRECTThis is false information. There are certain criteria when thrombolytic therapy would not be administered, but age is not one of them.D) "Since your mother was alert on admission, she is not a candidate to receive this medication."INCORRECTThis is false information. There are certain criteria when thrombolytic therapy would not be administered, but being alert is not one of them.13.Which nursing diagnosis has the highest priority?A) Impaired physical mobility.INCORRECTAlthough Nancy has right-sided paralysis, that is not the highest priority.B) Self-care deficit.INCORRECTAlthough Nancy has facial drooping, that is not the highest priority.C) Impaired social interaction.INCORRECTAlthough Nancy has difficulty communicating due to the aphasia, that is not the highest priority.D) Impaired swallowing.CORRECTAccording to Maslow's Hierarchy of Needs, physiological needs should be addressed first. Therefore, Nancy's dysphagia is the highest priority nursing diagnosis since she is at risk for aspiration.Nursing DiagnosisNancy spends 3 days in the Intermediate Care Unit. Once stabilized, she is transferred to a 40-bed medical unit. Nancy has right-sided paralysis, facial drooping, global aphasia, and dysphagia. Her IV fluids are discontinued, but she continues with a 20-gauge saline lock, now in the left forearm. She also still has a (foley) catheter. Other than bedrest, Nancy's healthcare provider prescribes sitting up in a chair 4 times a day.Because Nancy is right-handed and is having difficulty performing activities of daily living with the left arm, the nurse also includes the nursing diagnosis "self-care deficit" in the care plan.14.Which intervention would the nurse implement to address this nursing diagnosis?A) Use narrow grip utensils to accommodate a weak grasp.INCORRECTWide-grip utensils should be used to accommodate a weak grasp.B) Utilize plate guards when Nancy is eating.CORRECTPlate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. C) Discourage Nancy from using assistive devices.INCORRECTAssistive devices can be of great benefit and encourage independence.D) Recommend a regular type toilet seat with grab hand bars.INCORRECTThis intervention discourages client independence.Teaching/Health PromotionGail asks the nurse, "Why did Mom have this stroke? Do you think that I might have one since she had one?" The nurse and Gail discuss risk factors for a brain attack and ways to decrease the risks.15.Which condition is considered a non-modifiable risk factor for a brain attack?A) High cholesterol levels.INCORRECTThis is a modifiable risk factor.B) Obesity.INCORRECTThis is a modifiable risk factor.C) History of atrial fibrillation.INCORRECTThis is a modifiable risk factor.D) Advanced age.CORRECTPeople over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable risk factor means the client cannot do anything to change the risk factor. Gail tells the nurse she is going to go outside to smoke a cigarette and will only be gone for a few minutes.16.Which statement is warranted in this situation?A) "I should let you know that smoking is a strong risk factor for a brain attack."CORRECTThe nurse should teach Gail that smoking is a modifiable risk factor that could prevent her from having a stroke. Smoking increases the risk for hypertension, which is a risk factor for a stroke.B) "That is just fine. I will be here taking care of your mother."INCORRECTThis response enables, and possibly encourages, Gail to continue smoking.C) "Make sure you smoke in the smoking area only. The hospital has strict rules."INCORRECTThis response enables, and possibly encourages, Gail to continue smoking.D) "How long have you been smoking?"INCORRECTWhile this is useful information, it does not address Gail's decision to go out and smoke.Nursing InterventionsNancy is experiencing homonymous hemianopsia as the result of her brain attack.17.Which nursing intervention would the nurse implement to address this condition?A) Turn Nancy every 2 hours and perform active range of motion exercises.INCORRECTThat intervention would address the client’s risk for immobility due to paralysis.B) Place the objects Nancy needs for activities of daily living on the left side of the table.CORRECTHomonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side. C) Speak slowly and clearly to assist Nancy in forming sounds to words.INCORRECTThat intervention would address the client's verbal deficits due to aphasia.D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays.INCORRECTThis would address dysphagia.Nancy is experiencing pain in her right shoulder. The nurse is aware that up to 70% of clients with a brain attack experience severe pain in the shoulder that prevents them from learning new skills. Shoulder function helps clients achieve balance, perform transfer skills, and participate in self-care activities.18.Which intervention should the nurse implement when addressing this condition?A) Move Nancy by lifting with the affected shoulder.INCORRECTThe nurse should never lift or pull the client by the affected shoulder.B) Remind Nancy to perform active range of motion exercises daily.INCORRECTActive ROM exercises should be performed at least every 4 hours. Once a day is not enough to prevent contractures.C) Assist Nancy to keep the affected arm in a dependent position as much as possible.INCORRECTThe affected arm should be elevated to prevent dependent edema in the hand.D) Instruct Nancy to clasp the right hand with the left hand and raise both hands above the head.CORRECTThis exercise helps prevent "frozen shoulder" and will aid the nurse when moving or positioning the client.Gail tells the nurse, "One of the people in the waiting room was telling me about an operation that her mother had to prevent a stroke. Do you know anything about that?"19.How should the nurse respond?A) "There is currently no surgery that can help prevent a stroke."INCORRECTThis is not correct information.B) "That procedure is only done with small strokes, not like the one your Mom had."CORRECTThis surgery is indicated for clients with symptoms of transient ischemic attack (TIA), or mild stroke, found to be due to severe carotid artery stenosis or moderate stenosis with other significant risk factors. C) "Yes, it is a carotid endarterectomy, and your mother may be able to have one."INCORRECTThis is not correct information.D) "I am sure your healthcare provider will discuss that with you at a later date."INCORRECTThe nurse has the knowledge and responsibility to answer this question, even if Gail chooses to ask Nancy's healthcare provider about it later.ManagementThe nurse on the day shift is caring for Nancy and 4 other medical clients. There are 2 unlicensed assistive personnel (UAPs) on the unit assisting with the client care.20.Which nursing care task should the nurse delegate to the UAP?A) Assist Nancy to eat her breakfast.INCORRECTSince Nancy has dysphagia, the nurse should not delegate this high-risk task to the UAP.B) Flush Nancy's saline lock with 2 ml of normal saline.INCORRECTIV fluids are medications. Medication administration cannot be delegated to the UAP.C) Use a walker to help Nancy ambulate down the hall.INCORRECTNancy has right-sided paralysis and should be taught to walk by the physical therapist.D) Give Nancy a bed bath and change the bed linens.CORRECTThe UAP can assist Nancy with bathing and then change the bed linens. This task does not require professional judgment or expertise.A physical therapist (PT) places a gait belt on Nancy and is assisting her with ambulation from the bed to the chair. As she gets up out of the bed, she reports being dizzy and begins to fall. The PT carefully allows her to fall back to the bed and notifies the primary nurse.21.Which written documentation should the nurse put in the client's record?A) Client experienced orthostatic hypotension when getting out of bed.INCORRECTThe nurse is making an assumption that the dizziness was caused by orthostatic hypotension.B) PT reported that client became dizzy and was lowered back to the bed with the assistance of a gait belt.CORRECTThis documentation provides the factual data of the events that occurred.C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.INCORRECTNot all the pertinent facts are included in this documentation.D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed.INCORRECTA variance report should never be documented in the client's record.Nursing Care in the Rehabilitation UnitNancy is progressing physically and is transferred to the rehabilitation unit. She continues to have total right-sided paralysis, facial drooping, global aphasia, and dysphagia. She has an indwelling urinary (Foley) catheter. She is scheduled for 3 hours of physical and occupational therapy daily.??The rehabilitation team meets to review Nancy's plan of care.22.Which intervention should the nurse implement to prevent joint deformities?A) Place Nancy in a prone position for 15 minutes at least 4 times a day.CORRECTThis helps to promote hyperextension of the hip joints, which helps prevent knee and hip flexion contractures. B) Position the fingers so that they are totally flexed in a slight pronation position.INCORRECTThe fingers should be barely flexed and placed in supination (palm faces upward), the normal anatomical position.C) Place the elbow lower than the shoulder and the wrist lower than the elbow on the affected side.INCORRECTThe elbow should be higher than the shoulder and the wrist higher than the elbow to prevent edema and possible joint fibrosis that will occur and limit ROM if Nancy regains use of the arm.D) Apply splints to the arms and legs during the day but remove at night.INCORRECTBecause flexor muscles are stronger than extensor muscles, posterior splints should be applied at night to prevent flexion and maintain correct positioning during sleep.Nancy has difficulty communicating with the rehabilitation team and her daughter. Gail is very upset that her mother can't communicate and tells the nurse that Nancy has always been an eloquent speaker. Gail is helping her mother by answering questions for her and trying to anticipate what she wants.23.What action should the nurse implement to address this situation?A) Praise Gail for trying to anticipate her mother's needs.INCORRECTAlthough Gail should be encouraged and praised for helping her mother, the nurse should discourage this behavior. Nancy should attempt to do as much for herself as possible.B) Inform Gail that Nancy will start speech therapy soon.INCORRECTWhile this may be true, the nurse should address the situation.C) Discuss how to use a communication board with both Nancy and her daughter.CORRECTA communication board has pictures of common needs and phrases that help with communication. The nurse can easily teach this effective technique to Nancy and Gail. D) Explain that Nancy's speech will become clearer as she gets better.INCORRECTNancy's speech may become better, but it may not. This is false reassurance.24.Which rehabilitation team member is responsible for evaluating Nancy's dysphagia?A) The rehabilitation physician.INCORRECTThe physician does not evaluate dysphagia.B) The speech therapist.CORRECTThe speech therapist evaluates the client's gag reflex and ability to swallow, then makes recommendations regarding feeding techniques and diet.C) The case manager.INCORRECTThe case manager is usually a registered nurse that coordinates the client's care with the multidisciplinary team members.D) The occupational therapist.INCORRECTThe occupational therapist helps clients achieve independence in activities of daily living.Nutritional ConcernsBecause Nancy is unable to swallow effectively, not only is she at risk for choking, but she is no longer able to meet her nutritional needs and has lost 10 lbs. A gastrostomy tube is prescribed so that tube feedings can be administered. 25.Which intervention should the nurse implement while Nancy is receiving tube feedings?A) Keep the head of the bed at a 10-degree angle during the feeding.INCORRECTThe head of the bed should be elevated at least 30 degrees to prevent aspiration.B) Stop the tube feeding if the residual is greater than 10 ml.INCORRECTThe nurse should aspirate Nancy every 4 hours to ensure that the feedings are being digested. Usually a residual amount greater than 60 ml indicates that the next feeding should be held.C) Deflate the 20 ml gastrostomy balloon between feedings.INCORRECTThe balloon should be inflated to ensure that the feeding tube remains in place in the stomach.D) Cleanse the gastrostomy insertion site with soap and water daily.CORRECTBecause the skin around the gastrostomy tube may become irritated from the enzymatic action of gastric juices that leak around the tube, the stoma should be cleansed daily.The healthcare provider orders one 240 ml can of liquid nourishment diluted with one can of water to be infused over 8 hours. The feeding will be administered through an infusion pump, which infuses in ml/hr.26.At what rate would the nurse set the infusion pump?A) 40 ml/hr.INCORRECTRemember the formula for ml per hour.B) 60 ml/hr.CORRECTThe nurse must add 240 ml (fluid) plus 240 ml (water), which equals 480 ml. Divide 480 ml by 8 hours. The pump should be set at 60 ml/hr.C) 100 ml/hr.INCORRECTRemember the formula for ml per hour.D) 240 ml/hr.INCORRECTRemember the formula for ml per hour.Legal IssuesNancy appears depressed, and Gail reports that her mother seems to have lost all hope. Gail reminds the staff that her mother has a Living Will and a Do Not Resuscitate order. Gail has a Durable Power of Attorney for Health Care that was signed over 2 years ago.A week later, Gail is sitting at the bedside when Nancy starts to gasp for air. Gail yells for the nurse. When the nurse arrives, Nancy is not breathing. The nurse assesses Nancy's apical pulse but cannot hear anything.27.Which intervention should the nurse implement?A) Call a code immediately and reposition Nancy's airway.INCORRECTThis is not the correct action to take in this situation.B) Continue to stay at Nancy's bedside and hold Gail's hand.CORRECTThe client has a DNR order. Therefore, no action should be taken. Providing support to the daughter as her mother dies is the best nursing action in this situation. C) Provide Nancy with 2 rescue breaths and assess the carotid pulse.INCORRECTThis is not the correct action in this situation.D) Turn Nancy to the left lateral position and assess the apical heart rate.INCORRECTThis is not the correct action in this situation.The telephone at Nancy's bedside starts ringing. The nurse answers the phone. The caller is one of Nancy's neighbors, wanting to know how she is doing.28.How should the nurse respond?A) "I am so sorry, but Nancy just passed away."INCORRECTThis violates the client's right to confidentiality.B) "I will have Nancy's daughter call you at a later time."INCORRECTThe nurse should not speak for Nancy's daughter. Gail may not want to call people back at this time.C) "I am sorry, but I am unable to give you any information."CORRECTAccording to HIPAA, the client has a right to confidentiality. The nurse cannot give any information to someone that does not have a "need to know."D) "Let me have your number, I will call you back in a few minutes."INCORRECTThe nurse cannot give any information to Nancy's neighbor.The nurse remains with Gail at Nancy's bedside. The healthcare provider is called and pronounces Nancy's death. Gail tells the nurse that Nancy wanted to be an organ donor.29.Which action should the nurse implement?A) Obtain the necessary permits and notify the regional organ donor center.INCORRECTThis may be done, but another action should be implemented first.B) Explain that Nancy can only be a tissue donor, not an organ donor.CORRECTGail needs the correct information. The client must be on a ventilator and declared "brain dead" prior to donating body organs such as the heart, lungs, liver, and pancreas (oxygen is needed for viability). Corneas, skin, bones, and joints can be donated from deceased donors who suffer cardiac death. These tissues can be recovered up to 24 hours after death. In some circumstances, kidneys can also be obtained from non-ventilated deceased clients.  C) Explain that since Nancy was on heparin recently she cannot be a donor.INCORRECTThis is false information. Heparin does not affect the ability to donate organs or tissues.D) Remove all of Nancy's tubes and wash her body.INCORRECTThis is not the first action that the nurse should implement. Some facilities do not allow the nurse to remove the client's external tubes. Hospital policy/procedures should be followed.Spiritual ConsiderationsNancy was a Roman Catholic, and although she received the sacrament known as "Anointing of the Sick" shortly after her brain attack, Gail wants her mother to receive Last Rites immediately.30.Which action should the nurse implement?A) Notify the chaplain services immediately so the priest can come to the bedside.CORRECTThe nurse must advocate for the client and family and should allow Nancy to have Last Rites. B) Explain since Nancy has already received Anointing of the Sick, there is no need to call a priest.INCORRECTThe nurse must support the client's religious beliefs.C) Tell Nancy she must contact her own priest to come and bless Nancy.INCORRECTThe nurse can support the client's wishes and religious beliefs by actively assisting her while she is grieving.D) Discuss how long Gail thinks it will take for a priest to come to the hospital.INCORRECTThe nurse must support the client's religious beliefs and not worry about the length of time it would take to notify a priest.Gail is crying quietly while sitting in Nancy's room. Gail tells the nurse that her mother wanted to be cremated and to have her ashes thrown over the lake where Nancy and her husband met over 50 years ago. Gail wants to bury her mother beside her father in the local cemetery and tells the nurse, "I just don't know what I should do."31.How should the nurse respond?A) "You should do what your mother wanted."INCORRECTThis is advising and is not a therapeutic response.B) "I will contact the priest and ask him to talk to you about this."INCORRECTThis is "passing the buck" and is not a therapeutic response.C) "You seem really confused about what to do. Would you like to talk about it?"CORRECTThis is a therapeutic response and addresses Gail’s feelings.D) "Isn’t being cremated against Roman Catholic beliefs?"INCORRECTIt is not the nurse’s responsibility to question Roman Catholic beliefs.The priest arrives and blesses Nancy. He also helps Gail reach a decision about whether to follow Nancy's wishes for cremation or bury Nancy next to her husband.Case OutcomeNancy's body is taken to the Tissue Donor Bank, and her wish to be a tissue donor is honored. Gail decides to respect her mother's wishes by having her body cremated and scattering most of her ashes over the lake. Gail decides to scatter a small amount of the ashes at her father's grave site. Gail thanks the entire nursing staff, as well as the rehabilitation staff for the wonderful nursing care her mother received. She tells the staff, "Knowing that my mother received such good care at the end makes her death a little easier to bear."