Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?

Correct Answer: D

Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.

Correct Answer: B

Rationale: Returning after a few minutes and staying until the patient takes the medication ensures safe administration, adhering to the 'Five Rights' right patient, drug, dose, route, and time. The nurse verifies ingestion, preventing errors like missed doses or misuse, and documents accurately. Leaving medication unattended risks it being lost, taken incorrectly, or accessed by others, violating safety protocols. Instructing without supervision assumes compliance but lacks confirmation, potentially falsifying records if the dose isn't taken. Waiting briefly then leaving it bedside still neglects oversight. Returning and remaining present balances respect for the patient's privacy with accountability, ensuring the medication reaches its intended recipient at the prescribed time, critical for treatment efficacy and legal standards in nursing practice.

Correct Answer: A

Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.

Correct Answer: A

Rationale: Health promotion enhances well-being and prevents disease proactively administering immunizations (e.g., measles vaccine) exemplifies this, boosting immunity before illness strikes. Giving a bedbath is hygiene, not promotion supportive, not preventive. Preventing complications post-accident is tertiary prevention, managing existing issues, not promoting health preemptively. Diagnostic procedures (e.g., blood tests) detect, not promote assessment, not prevention. Immunizations align with health promotion's focus on empowering clients against disease, a core nursing role in public health, making this the standout example.

Correct Answer: B

Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.