A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?
Heating pad
Body lotion
Soft blanket
Moist clothes
The Correct Answer is C
The correct answer is Choice C. Soft blanket.
Choice A rationale:
A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.
Choice B rationale:
The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.
Choice C rationale:
The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.
Choice D rationale:
Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D. Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
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