Ch 14 Cna Test Review Which if Following Is One of Nutritional Problems

Patient Care: Life-Limiting Weather in Developed Patients

i.	Alzheimer disease is associated with what characteristics?
		a. Pre-clinical and symptomatic phases
		b. Lewy body deposits
		c. A more accelerated turn down in older patients
		d. Deadening, irreversible organ failure
Alzheimer disease is one blazon of dementia, with a known pre-clinical phase during which pathophysiologic changes begin to occur, followed past a symptomatic phase where cognitive and functional decline becomes noticeable. Lewy torso deposits in the encephalon are associated with Lewy body dementia only. The degree of dementia progression oftentimes depends on underlying factors, although there is some evidence suggesting that early on-onset Alzheimer patients progress more speedily. Irreversible organ failure is not a hallmark characteristic; instead, hurting, constipation, and behavioral changes are the most common symptoms. Wrong answer. Please choose some other reply.

2.	You are the nurse on-call and receive a call from a continuous care nurse who states that her patient has started to have "rattling" secretions and the patient'due south married woman is very concerned. You know from report that this patient is actively dying. What would be the most appropriate response?
		a. Reposition patient on his side
		b. Administrate furosemide
		c. Suction the patient
		d. Order oxygen for the patient
Noisy, congested respirations (known equally "terminal secretions") are very mutual during the dying process, and are too sometimes referred to as a "death rattle". Typically, they do not cause discomfort for the patient, only tin can be very distressing to family members. Repositioning the patient by turning him on his side tin can be helpful to subtract the noise associated with this state of affairs. Anticholinergics tin besides exist administered, but typically, one time the secretions first, anticholinergic effectiveness is limited. Wrong answer. Delight choose another answer.

3.	Which characteristics are most closely associated with terminate-phase renal illness?
		a. xx% or less of normal renal office exists; result of coronary artery disease
		b. Upshot of booze misuse; only handling is dialysis
		c. x% or less of normal renal office exists; result of diabetes
		d. Affects Hispanic population disproportionately; symptoms include polyuria
End-stage renal disease (ESRD) is diagnosed when <ten% of normal renal part exists, and is often a effect of diabetes or hypertension. Booze misuse or comorbidities such equally coronary artery affliction, peripheral vascular illness, or malnutrition may exist present, but are not causative factors. Treatment includes dialysis, but also kidney transplantation. African Americans, not Hispanic populations, are disproportionately affected by ESRD. Oliguria, not polyuria, is a symptom of ESRD. Wrong reply. Please choose another answer.

4.	Mary is a 73-year-one-time patient with a 50-yr history of smoking and a diagnosis of emphysema. She is very thin with a barrel chest, has intermittent dyspnea both at balance and with exertion, and supraclavicular retractions on exertion. What not-pharmacologic intervention would likely improve dyspnea in this patient?
		a. Lowering the head of the bed
		b. Positioning in the tripod position
		c. Deadening, deep meditative breathing through the olfactory organ
		d. Guided imagery
Patients with emphysema may find some relief from dyspnea by leaning forward while sitting, and placing artillery over a table ("tripod position"), due to the lengthened tension-land of the diaphragm in this position. Lowering the head of the bed would likely worsen dyspnea; pursed mouth-breathing, rather than deep nose-breathing, would exist of greater benefit to lessening dyspnea; although guided imagery may meliorate mood, evidence does not demonstrate that information technology affects dyspnea straight. Incorrect answer. Please choose another answer.

5.	John is a new hospice patient with eye failure. John reports a six-pound weight proceeds since his discharge from the hospital iii days agone. The nurse notes that John has dependent peripheral edema 2 +, and he reports feeling nauseated and with poor ambition. Based on these findings, what is the pathophysiology of John's heart disease?
		a. Systolic dysfunction, with poor cardiac output
		b. Diastolic dysfunction, with poor ventricle filling
		c. Decreased ejection fraction
		d. Generalized organ perfusion failure
John'due south symptoms are due to right sided (diastolic) heart failure, when the ventricle does non fill up adequately, leading to a generalized edema of the extremities and the hepatic system. Symptoms of correct sided failure include nausea, anorexia, peripheral edema, ascites, weakness, and weight gain. Poor cardiac output, decreased ejection fraction, organ perfusion failure are indicative of left-sided heart failure. Wrong respond. Delight choose another answer.

vi.	A nurse is coming together a patient for the first fourth dimension. When introducing himself, the nurse notes a serial of symptoms that are concerning for acute stroke. Which symptoms are associated with acute stroke?
		a. Hyperventilation and bowel incontinence
		b. Difficulty agreement speech and blurry vision
		c. Airsickness and dyspnea
		d. Generalized weakness and dysphagia
Acute stroke is associated with aphasia (which may include difficulty with both understanding and with verbalizing speech), ataxia, numbness or paralysis of limbs or confront, vision disturbances, and headaches, which may illicit vomiting. The other symptoms are not indicative of acute stroke symptoms. Wrong answer. Delight choose another reply.

Patient Care: Pain Management

7.	Which of the following most accurately describes "breakthrough" pain?
		a. Associated with pathological fractures
		b. Refers to a new psychological or spiritual insight
		c. Tin can occur equally end-of-dose failure
		d. An attribute of opioid pseudo-addiction
Quantum pain is intermittent episodes of pain that occur in patients with chronic pain. This type of pain tin be related to some blazon of activity, of unknown origin, or tin occur as analgesic failure at the end of a pain medication'due south menstruation of effectiveness. Opioid regimens for hurting management in the hospice and palliative care setting should include a long-interim agent, in one case dosing need is established, and a brusque-interim agent to cover episodes of breakthrough pain. Incorrect answer. Delight choose another answer.

8.	Madge is an 88 twelvemonth-old with end stage colon cancer, who is transitioning. She has been minimally responsive for the past six hours, simply opens her eyes in response to her proper name.  She is restless at times with furrowing of her brow. She is still swallowing her secretions, and sucks on the oral sponge when mouth intendance is provided. Prior to her change in status, she was receiving Oxycontin 40 mg po tablets q12 hour ATC with liquid oxycodone 8-12 mg po q2hrs prn for breakthrough pain. In light of Madge's alter in level of consciousness, what changes should exist fabricated to her pain management regimen?
		a. Convert to IV infusion
		b. Catechumen to subcutaneous infusion
		c. Convert to liquid dosing orally
		d. Convert to fentanyl patch
Since the oral road is always preferred if possible, Madge should be converted to liquid dosing of her current long-interim hurting medication q 4hrs ATC (catechumen from Oxycontin® to liquid oxycodone), while maintaining the same dosing as currently ordered for breakthrough pain. Since well-nigh liquid forms are quite full-bodied, fifty-fifty patients who are minimally responsive can tolerate such pocket-size volumes in the buccal space and typically maintain first-class pain control. Incorrect respond. Please cull another respond.

9.	Which patient is at most risk for nether-treatment of pain symptoms?
		a. 86-year old female person with COPD, living in an assisted living facility
		b. 74-year old male person with congestive middle failure, living with his wife
		c. 51-yr old male, recently diagnosed with ALS; a former weight lifter
		d. 42-yr old female with early-onset dementia, living with her sister.
A frequent misconception is that younger patients with few co-morbidities are at greatest take chances for under-treatment for pain, just in fact the elderly, minorities, and women are most at run a risk for under-handling. Of the iv case scenarios, the 86-twelvemonth quondam has two of the 3 risk factors. Incorrect answer. Please choose another respond.

10.	Margaret is an 87-yr old with chest cancer that has metastasized to bone and brain. She lives alone, and is checked in on by a neighbor every other day. During a home visit, Margaret complains of dull, constant pain in her back and breastbone. The nurse notes that the oxycodone tablets that he had counted out for her for the last ii days are still in the pill box; Margaret cannot explain why she did non take them as prescribed. This is the second occasion when the nurse has constitute tablets not taken. What is an advisable pain direction strategy for Margaret?
		a. Margaret should exist admitted to an inpatient hospice for pain control.
		b. The oxycodone should exist replaced with equianalgesic transdermal fentanyl.
		c. The oxycodone should be replaced with an equianalgesic liquid morphine.
		d. A neighbour should be tasked to give Margaret her medications.
Transdermal fentanyl, also known as a fentanyl patch, is a good choice for individuals with pain who cannot swallow or exercise not remember to take their medication, and would need to be titrated to effect for this patient. Information technology is a specially practiced choice for Margaret because she may be forgetful due to her brain metastasis, which would non improve by providing liquid morphine instead of tablets. As she does not live with a caregiver, depending on the neighbor to assure adequate pain management is not an effective plan. Equally Margaret is not in pain crunch, symptom control efforts should be initiated and the effect evaluated before referral to an inpatient hospice setting. Incorrect reply. Please cull another answer.

11.	What should exist prescribed concurrently with whatever opioid regimen?
		a. Ondansetron
		b. Diphenhydramine
		c. Senna
		d. Pamidronate
Equally constipation is a significant side effects of opioid therapy, whatever patient on an opioid should likewise be prescribed a prophylactic bowel regimen to preclude or manage constipation. Senna is a simulant laxative that chemically stimulates the bowel to increase motility. Ondansetron HCl is a 5-HT3 receptor antagonist, used to forbid nausea and vomiting; diphenhydramine is an antihistamine used to treat opioid- induced pruritus; pamidronate is a bisphosphonate used as an adjuvant to opioids for os pain. Wrong answer. Please choose another answer.

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12.	Jordan is taking continuous-release morphine every 12 hours for pain command, and has a short-acting prn opioid for break through pain. He is experiencing end-of-dose failure at 9-10 hours. What would be the most advisable intervention to manage Jordan's pain?
		a. The dose should be decreased every 12 hours, but the short-acting prn dose should exist increased by 25%.
		b. An adjuvant therapy such as a corticosteroid should exist added.
		c. Jordan should be switched to an equianalgesic alternative opioid
		d. The dosing interval of the continuous-release morphine should be decreased to every 8 hours, at the same dose, with no change in the prn dosing
Hashemite kingdom of jordan is experiencing end-of-dose failure, which indicates that in the last hours of the dosing bicycle, the blood levels of the drug are decreasing before uptake of the side by side scheduled dose. This is different than breakthrough hurting, characterized by episode of pain despite control of continuous baseline pain. By shortening the round-the-shut drug interval, Jordan will experience more stable drug blood levels. Increasing the prn dosing would only effect in a short-acting bolus only prior to the side by side dosing cycle and could crusade sedation and other side effects. A switch to another opioid is non necessary as this is typically done due to an undesirable side effect. A corticosteroid would not provide the desired pain management result in the terminal hours of the dosing cycle. Incorrect answer. Delight choose some other answer.

Patient Care: Symptom Management

xiii.	Of the following, which may indicate a poor prognosis for the hospice patient with a diagnosis of stop-phase cardiac disease?
		a. Infection
		b. Edema
		c. Bleeding
		d. Unexplained syncope
Unexplained syncope, also as previous cardiac arrest with resuscitation, and an embolic stroke originating from the cardiac system are all indicators of poor prognosis in this patient population. Incorrect answer. Please cull another answer.

14.	When a hospice patient is facing increasing weakness, with increased fatigue and decreased mobility, which of the following is an important aspect of supporting the patient'south intendance needs?
		a. Prioritizing energy use
		b. Honoring the wishes of family unit members
		c. Remaining equally mobile as possible
		d. Seeing as many visitors every bit possible
Prioritizing energy use is an important attribute of supporting the hospice patient who is experiencing progressive weakness and fatigue. Helping the patient to identify which activities are almost important to concrete, emotional and spiritual needs empowers the patient to spend limited energy on those aspects that thing nigh to them. Wrong respond. Please choose another answer.

xv.	Terri has an indwelling pleural catheter in identify for intermittent drainage of her pleural effusion. The nurse is present to provide education on the use of the catheter at home. Which point is of import for the nurse to stress to Terri to avoid vasovagal symptoms?
		a. The drainage should occur slowly and continuously over an 8-60 minutes period.
		b. No more than than 1-1.v liters of fluid should be removed at whatsoever one time.
		c. It is of import to fully drain the pleural space each time the catheter is accessed.
		d. The catheter can but exist accessed by a nurse.
To avoid vasovagal symptoms (tachycardia, hypotension, fainting), it is important to draw the fluid off slowly with no more than than i-i.5 liters removed at whatsoever one time. Fully draining the pleural space (if more than i.five liters is present) could outcome in pain, vasovagal responses, and cough. In the palliative setting, information technology is ideal to have a caregiver instructed on how to properly access the catheter. Drainage should never occur over an viii-hour menstruation, as prolonged catheter admission can effect in infection or embolus. Incorrect answer. Delight cull another answer.

sixteen.	Daryl has an incomplete bowel obstacle secondary to metastatic ovarian cancer. She is experiencing meaning intestinal pain and is vomiting fecal thing. She and her family desire non-pharmacologic interventions only. Which intervention is likely to exist the nearly effective?
		a. Bowel remainder
		b. High cobweb diet
		c. Foley catheter
		d. Nasogastric tube
Insertion of a nasogastric tube for decompression venting and emptying of stomach contents is the about appropriate intervention at this stage of obstruction. Bowel remainder is necessary, but bowel balance alone will not empty the tummy contents and hopefully reduce vomiting. A Foley catheter will not improve the obstruction; introduction of food while the obstacle is nowadays volition only complicate the situation. Incorrect respond. Delight choose another reply.

17.	Michelle has metastatic head/cervix cancer and is in the last stages of life. She is cared for at home by her niece. In the last 24 hours she has become increasingly restless, and is repetitively attempting to become out of bed, while calling out in distress. Which grouping of interventions would exist the most appropriate for Michelle at this fourth dimension?
		a. Transfer Michelle from home to an inpatient hospice unit; brainstorm 4 morphine.
		b. Confine Michelle to bed; discontinue her neuroleptics.
		c. Dim the lights in Michelle's room; administer haloperidol.
		d. Raise the caput of Michelle's bed; obtain a 24-hour sitter.
Michelle is experiencing hyperactive delirium, commonly seen at end of life but prior to non-responsiveness. Dimming the lights will reduce sensory stimulation and may calm Michelle. Haloperidol is commonly administered for this symptom and is typically effective. Transferring Michelle immediately would likely exacerbate her symptoms; although morphine would cause sedation, information technology is not the near appropriate drug for these symptoms. Confining Michelle is inappropriate; discontinuing whatever current medications would only exacerbate symptoms. A sitter is an appropriate intervention as Michelle may be at hazard for falls, simply raising the head of the bed is ineffective for these symptoms. Incorrect answer. Delight choose some other answer.

Care of Patient and Family

eighteen.	Which service for the hospice patient would exist paid for past the Hospice Medicare/Medicaid do good?
		a. Room and board in a nursing home facility.
		b. Treatment intended to cure the hospice-qualifying concluding illness
		c. Care for the terminal affliction from more than one hospice provider
		d. Transportation and visits to the emergency room that are arranged past the hospice provider
The Hospice Medicare and Medicaid Benefit pays for outpatient services such equally emergency room visits when arranged by the hospice squad. The benefit does not cover room and board for hospice services in a private home or room and lath in a nursing dwelling; information technology does not comprehend prescription drugs or treatment intended to cure the terminal illness. The benefit also requires that all care for the terminal illness  is given by the hospice provider called, with the exception of the patient's regular doctor or nurse practitioner, chosen to exist the attending physician for the hospice care. Wrong reply. Please choose some other answer.

19.	Afterwards a patient's death, how long are bereavement services available to families and other individuals associated with the patient?
		a. Based on the degree of bereavement risk assessed, services can go along indefinitely.
		b. Up to six months for family members and up to 6 weeks for other individuals associated with the patient.
		c. Up to one year following the death of the patient.
		d. Hospices have no obligation to provide bereavement services for any specific period of time.
Medicare hospice regulations require that the hospice must provide bereavement services to the family and whatsoever other individuals that are identified on the bereavement care plan for up to 1 year following the patient'southward death. In that location is no distinction between direct family members and other individuals associated with the patient. Incorrect answer. Please choose another reply.

20.	Heidi is in her terminal days of life, being cared for by her husband and adult children. Over the last week she has increased her sleep from 16 to xx hours per day and is taking only sips of water and juice. Her daughter calls the nurse, concerned that Heidi suddenly became alert and clearly demanded that she needs to get upward and get into line with people outside who are waiting for her. These statements by Heidi have upset the family, but Heidi is comforted by them. What is an appropriate intervention for this family?
		a. Instruct the family that speaking in metaphors when patients near terminate of life is common, and that Heidi may be trying to communicate that she is gear up to die.
		b. Encourage the family to clearly state to Heidi that there are no people outside waiting for her
		c. Inform the family that Heidi is delusional due to the pain medication she is receiving and that they should not respond to these statements
		d. Instruct the family to increase the hurting medication dose that Heidi is receiving, equally this is an indicator of pain
Patients may employ apologue or metaphors to describe terminate of life experiences, to include descriptions of visions or discussions with others, and preparatory statements such every bit getting ready for a trip, packing, meeting one-time friends and family, or standing in line preparing to become somewhere. Denying Heidi'southward beliefs would probable upset her without positive effect; although information technology is possible that Heidi has delirium, her behavior/statement does not warrant increasing her hurting medication; as well, ignoring her statements would probable upset Heidi. Incorrect answer. Delight choose another answer.

21.	Ayaan has metastatic pancreatic cancer and is cared for at home by his married woman and adult children. During a contempo visit, the nurse notes that his symptoms have dramatically worsened and he is nearing the terminal days of life. The nurse knows that the family'due south spiritual behavior concord that speaking about dying is considered "giving up", and is non acceptable. However, after the nurse's assessment, Ayaan's wife asks the nurse how he is doing, and happily reports that she thinks he is "improving". What would be the nigh advisable response from the nurse?
		a. "It's time to begin talking well-nigh Ayaan's death."
		b. "I wish that I had better news to tell you."
		c. "Permit's call the medical director to give you an update."
		d. "You are not helping Ayaan by avoiding the facts."
Using terms such every bit "I wish" and "I had hoped" acknowledge the changes that are obvious while respecting the family unit's spiritual wishes to not discuss death directly. Confronting the wife past accusing her of not being helpful or non being ready to talk about decease devalues their beliefs almost decease; diverting the discussion to the medical director may exist helpful, but is not the nigh advisable option. Incorrect answer. Please cull another answer.

Education and Advocacy

22.	Eric is a 69-year-former with terminate-phase esophageal cancer who has only returned home from the hospital after having a PEG tube placed. His wife, Margaret, will exist caring for him, and states that she learned how to give him his tube feedings in the hospital. What is the near effective mode of assessing Margaret's power to perform this chore?
		a. Enquire her to tell you how she performs it.
		b. Ask her to evidence you lot how she performs it.
		c. Enquire her to describe the instructions she was given.
		d. Ask her husband if she is performing it correctly.
Request her to bear witness you how she performs the skill is the near effective ways of demonstrating competency. After instructing patients/caregivers regarding any given skill or task, the post-obit should occur, as a minimum: (1) Request a statement of understanding; (ii) Spotter a return demonstration if advisable; and (three) Document the response. These are essential aspects of ensuring adult learning and patient prophylactic. Wrong reply. Please cull another answer.

23.	If a patient and family are struggling financially, which member of the IDT may be most helpful in identifying available community resource for back up?
		a. Hospice clergyman
		b. Hospice social worker
		c. Hospice aide
		d. Hospice director
The hospice social worker would the nearly appropriate member of the IDT to help a patient and family who are struggling financially. Hospice social workers hold a unique cognition of customs resources and expertise for accessing them. Incorrect answer. Please choose some other respond.

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24.	Lorna has metastatic ovarian cancer, and is in her final days of life. Throughout her hospice benefit flow she has rated her pain as viii or ix out of 10 consistently, and has required increasing doses of pain medication to exist comfy. In the last 24 hours she has go non-verbal. Her son is concerned that she will not be able to communicate her suffering to him. What would exist the about appropriate educational betoken to brand to her son?
		a. "At this betoken she is no longer feeling whatsoever hurting."
		b. "We assume that her pain will escalate, so will simply keep increasing her pain medication from this betoken on."
		c. "When patients cannot communicate verbally, we look for behavioral changes that point that pain is present."
		d. "Once a patient is non-exact, we initiate terminal sedation as a way to manage pain."
Changes at end of life may distress family unit members, to include loss of direct communication with the patient. It is important to educate families that the patient's behavior will and then exist the all-time indicator of hurting and may include behaviors such every bit restlessness, musculus rigidity, grimacing, guarding, crying, moaning, irritability, diaphoresis, passivity, or aggression. A patient who has experienced pain upward to the point of being non-exact is unlikely to stop having pain, and the nurse should assume that pain direction must remain a priority; also, in that location is no reason to assume that pain will escalate, and then ongoing assessment is necessary. Initiating terminal sedation only for becoming non-verbal is inappropriate. Incorrect answer. Please cull another answer.

Interdisciplinary / Collaborative Practice

25.	Which argument is well-nigh accurate regarding palliative/hospice interdisciplinary teams (IDT)?
		a. All squad members tin can vocalism opinions, merely the medical manager is the concluding decision-maker
		b. Centers for Medicare & Medicaid Services (CMS) requires the palliative IDT to include a volunteer as a member of cadre services
		c. Patients and their families are considered members of the IDT.
		d. Each professional field of study operates independently to provide the most expansive care
The IDT includes patients and families as members to maintain the patient/family centered focus; all treatment plans are developed with the patient and family. The medical director is not the but leader in IDTs; controlling is achieved through coordination among all team members. CMS requires hospice IDTs to include a volunteer, non palliative IDTs. When professional disciplines operate independently, they role as a multidisciplinary team, just are not interdisciplinary, performance interdependently and often with overlapping roles. Wrong answer. Delight choose another reply.

26.	Co-ordinate to Medicare guidelines, how ofttimes does a registered nurse demand to make a visit to the patient's home for the purpose of supervising a hospice aide?
		a. One time every 30 days
		b. In one case every 7 days
		c. Once every 14 days
		d. Once every benefit period
According to the Medicare Atmospheric condition of Participations for Hospices, a registered nurse must brand a visit to the patient'due south home no less often than every xiv days for the purpose of supervising the care of the hospice aide. The hospice aide does not need to be present during the visit, unless an area of concern has been discovered. Incorrect answer. Please choose some other answer.

27.	What would exist the best option for involving the patient and family in the IDT give-and-take in the hospice residential setting, if they would like to participate?
		a. Ask them to nourish the meeting in the conference room.
		b. Hold the meeting in the hall outside the patient's room.
		c. Hold the meeting at the patient's bedside.
		d. Ask them to attend the meeting in the managing director's office.
The all-time choice for involving the patient and family in the IDT discussion in the hospice house setting would exist to hold the meeting at the patient's bedside. This would allow all parties to participate within the privacy of the patient'due south room. Incorrect respond. Please choose another answer.

Professional person Issues

28.	What is the all-time practice regarding use of the electronic wellness record in patient intendance?
		a. Signal of service documentation
		b. Documentation for all patients in ane sitting
		c. Documenting in the office
		d. Documenting before the end of the 24-hour interval
Point of service documentation is documentation performed  during the patient care visit and is the all-time practice regarding use of the electronic health record in patient care. Since hospice and palliative intendance is provided in an interdisciplinary manner, several professionals may be accessing the same record to review collaborative notes within the same day. Delayed documentation creates a bulwark to optimal patient intendance by making vital information inaccessible to other care providers. There are many benefits to point of service documentation, including increased accuracy in the patient care record, and decreased staff burn-out. When documentation is completed during the patient care visit, instead of subsequently hours, hospice staff tin can bask personal time for self-care, instead of patient care. Incorrect answer. Please choose some other respond.

29.	You accept recently started caring for a new patient who is a member of your church, and the patient permitted news of her hospice admission to exist added to the weekly church announcements. At Bible study, a mutual friend asks how she is doing. What is the most appropriate response?
		a. Provide an update on your patient's status.
		b. Ask her to talk to the pastor.
		c. Kindly reinforce that you cannot share personal data.
		d. Ask the group to pray for her.
HIPAA regulations protect patient privacy in all settings, and then it would not be advisable to share whatever data regarding your patient's status. In add-on to the protection that this affords your patient, this also lets others know that if they or a loved i ever needs hospice care, their data will too remain confidential. Incorrect answer. Please choose another answer.

thirty.	Although some variations in country laws exist, mostly, a therapy, including palliative and terminate of life care, can be withheld or withdrawn under which condition?
		a. The patient's legal surrogate refuses it.
		b. Only when the patient themselves refuses it.
		c. The interdisciplinary team determines that farther therapy causes existential pain.
		d. Merely when an ethics committee investigation is conducted.
In general, withholding or withdrawing therapy, also known as allowing natural death, can exist ethically justified and can exist determined by the patient's legal surrogate or the patient themselves. The interdisciplinary team lone does non have the authority to initiate withholding or withdrawing therapy; an ethics committee meeting may exist helpful to define the state of affairs, but is not required. Incorrect answer. Please cull another answer.

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