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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The sigmoid colon is the last part of the large intestine before the rectum. It functions to store fecal material and absorb water and electrolytes. Fecal material passing through the sigmoid colon tends to become more solid as water is absorbed, resulting in a more formed stool compared to other parts of the colon.
A. The transverse colon is located in the upper abdomen and is responsible for further absorption of water and electrolytes from the stool. Fecal material passing through the transverse colon tends to become more solid as water is absorbed, but it may not be as solid as stool from the descending colon or sigmoid colon.
B. The ascending colon is where stool is in a more liquid form as it moves up from the cecum. It undergoes further absorption of water and electrolytes as it travels through the colon, but it typically does not produce solid fecal output.
C. The ileum is the final portion of the small intestine and connects to the large intestine (colon). Stool passing through the ileum is still in a relatively liquid state as it contains undigested food particles, bile salts, and digestive enzymes. The primary function of the ileum is absorption of nutrients rather than water reabsorption, so fecal output from an ileostomy is usually more liquid.

Correct Answer is C
Explanation
C. Encourage the client to discuss his feelings about his health status: This option directly targets the affective domain by facilitating the expression and exploration of the client's emotions, attitudes, and beliefs related to their health status. Discussing feelings can help the client process emotions such as fear, anxiety, or frustration, and can promote emotional coping, self-awareness, and acceptance, all of which are important aspects of affective learning.
A. This option primarily involves the psychomotor domain, as it focuses on the client's ability to perform a physical skill (self-measurement of blood pressure). While this activity may indirectly influence the affective domain by building the client's confidence and sense of empowerment in managing their health, its primary focus is on the acquisition of motor skills.
B. This option engages the cognitive domain by encouraging the client to identify and express their informational needs about their diagnosis. While this approach can help address cognitive aspects of learning, such as knowledge acquisition and understanding, it may not directly target the affective domain unless the client's emotional responses and concerns are explicitly addressed.
D. Providing educational materials on exercise and nutrition guidelines can contribute to cognitive learning by imparting information about health behaviors but it may not directly address the affective domain unless the content specifically addresses emotional or motivational aspects of behavior change. However, if the brochures include content that inspires or motivates the client to adopt healthy lifestyle changes by appealing to their values, beliefs, or emotions, then it could indirectly influence the affective domain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
