A hospice client is being cared for by the nurse at home. The client begins to experience changes in respirations, coughing and becoming increasingly restless. Based on these clinical manifestations, the nurse would implement which of the following interventions? (SELECT ALL THAT APPLY) ( Medical orders are active for each intervention that would require a medical order.)

Call for transportation to the hospital

Initiate low-flow oxygen per nasal cannula

Provide relief from pain and from other distressing symptoms

Place the bed in semi-Fowler's position

Administer anti-anxiety medications as needed

Answer and Explanation

Correct Answer : C,D

C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.

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Correct Answer is A

Explanation

A. Gradual tapering of benzodiazepines under medical supervision is recommended to minimize withdrawal symptoms and rebound insomnia. The client should continue taking the medication as prescribed while discussing a tapering plan with their physician.
B. Abruptly stopping benzodiazepines can lead to withdrawal symptoms, including rebound insomnia, anxiety, agitation, and even seizures. Planning to stop medication on a specific day without medical guidance can increase the risk of withdrawal symptoms occurring during the workweek.

C. While it may be challenging to sleep without benzodiazepines initially, continued use can lead to dependence and tolerance, making it even more challenging to discontinue them in the future. Gradual tapering under medical supervision is the preferred approach.
D. Antihistamines are not typically used as substitutes for benzodiazepines in managing insomnia. Additionally, abruptly stopping benzodiazepines and switching to another medication without medical guidance can lead to withdrawal symptoms and inadequate management of insomnia.

A. Administer an intravenous sedative B. Assess the client for seizure activity C. Assist the client in slowed breathing techniques D. Check the client's blood pressure

Correct Answer is C

Explanation

C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.

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Naxlex Comprehensive Predictor Exams

A client who has been taking benzodiazepine sedative every night for two weeks wishes to stop taking them now. The nurse advises the client to:

Correct Answer is A

Explanation

A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?

Correct Answer is C

Explanation

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