Correct Answer: A

Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.

Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.

Correct Answer: B

Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being.


Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program.
Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments.
Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.

Correct Answer: C

Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (
A) and intravenous sedation (
B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (
D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.

Correct Answer: B

Rationale: The correct answer is B because applying an insulin sliding scale method based on research is an example of evidence-based practice. This method is derived from scientific evidence and research studies, ensuring the best outcomes for the patient. The other choices lack the same level of evidence-based rationale: A is based on a protocol, which may not be evidence-based; C is a standard safety practice, not necessarily evidence-based; D is a decision based on hospital policy or practicality, not specifically evidence-based.

Correct Answer: C

Rationale: The correct answer is C: “The fistula will be usable in about 4 to 6 weeks.” The rationale for this is that an arteriovenous fistula typically requires 4 to 6 weeks to mature and be ready for use. During this time, the fistula develops the necessary blood flow for efficient dialysis.


Choice A is incorrect because immediate use of the fistula is not recommended as it needs time to mature.
Choice B is incorrect as it underestimates the time needed for the fistula to heal and mature.
Choice D is incorrect as the usability of the fistula is not dependent on the manufacturer but rather on the patient's individual healing process.