A client with Amyotrophic Lateral Sclerosis (ALS) tells the hospice nurse they do not want to be intubated and placed on mechanical ventilation.
How should the nurse best respond?
"You should discuss your wishes with your healthcare provider.”.
"What would you prefer I do if you experience difficulty breathing?"
"Incentive spirometer use every hour will delay the need for being placed on the ventilator.”.
"Why don't you want to be on the breathing machine?"...
The Correct Answer is B
Addressing end of life care for patients with neurodegenerative diseases requires therapeutic communication and clarification of advance directives. The nurse must apply principles of patient advocacy and ethics to ensure that specific treatment preferences are understood and documented for future implementation.
Choice A rationale
While the healthcare provider must be informed, this response shifts the responsibility away from the nurse at a critical moment of sharing. The nurse should first explore the patient preferences to provide comprehensive support and advocate for their wishes.
Choice B rationale
This open ended question facilitates an exploration of the patient values and specific desires for comfort care. It allows the nurse to document alternative interventions, such as morphine or oxygen, while respecting the patient refusal of invasive life support.
Choice C rationale
An incentive spirometer helps with lung expansion but will not prevent the ultimate neuromuscular respiratory failure associated with ALS. Giving false hope about delaying ventilation is nontherapeutic and ignores the patient expressed desire to avoid intubation entirely.
Choice D rationale
Asking why can be perceived as defensive or judgmental in therapeutic communication. It may make the patient feel they need to justify their choice, rather than allowing them to express their feelings and plan for their end of life..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This scenario requires understanding neurovascular pathophysiology following head trauma. Knowledge of early versus late signs of intracranial pressure is essential to identify neurological deterioration and prevent brain herniation. Clinical assessment focuses on mental status changes and autonomic vital sign stability.
Choice A rationale
Tachycardia is typically not a sign of increased intracranial pressure. Instead, Cushing triad occurs as a late sign, characterized by bradycardia, widened pulse pressure, and irregular respirations as the brainstem undergoes significant compression and ischemia.
Choice B rationale
Amnesia is a common finding following traumatic brain injury due to localized tissue damage or concussion. However, it is a static deficit rather than a dynamic indicator of rising pressure within the rigid cranial vault.
Choice C rationale
Hypotension is not an indicator of increased intracranial pressure. In the Cushing response, the body increases systolic blood pressure to maintain cerebral perfusion pressure against the rising resistance of the swelling brain tissue and cerebrospinal fluid.
Choice D rationale
Restlessness is an early sign of increased intracranial pressure resulting from decreased cerebral oxygenation. As pressure rises, the brain becomes hypoxic, leading to agitation, irritability, and decreased level of consciousness before more severe physical signs manifest.
Correct Answer is D
Explanation
This scenario assesses management of post-thoracotomy chest tubes and stable respiratory findings. Knowledge of pleural space physiology, normal post-operative healing, and chest tube safety protocols is required to differentiate between expected recovery milestones and critical complications requiring urgent intervention.
Choice A rationale
Clamping chest tubes is contraindicated unless specifically checking for leaks or changing the drainage system. It risks tension pneumothorax by trapping air or fluid within the pleural space, which can lead to mediastinal shift and cardiovascular collapse.
Choice B rationale
Suction is typically maintained at -20 cm H2O to facilitate lung re-expansion. Increasing suction without a provider order can cause tissue trauma or exacerbate air leaks. The current respiratory rate and oxygen saturation indicate effective drainage and ventilation.
Choice C rationale
Bubbling in the water seal chamber indicates an air leak, but the current clinical data does not suggest one. A respiratory rate of 22 and 94 percent saturation are common 24 hours post-surgery while recovering from anesthesia.
Choice D rationale
Stable vital signs and manageable incisional pain are expected findings. Continuing to monitor ensures the lung remains expanded and the drainage system functions correctly. The SpO2 of 94 percent is acceptable during the early recovery phase after thoracotomy.
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