A nurse enters a hospice patient’s room to perform an assessment after receiving the morning report.
The outgoing nurse reports that the patient is showing loss of appetite, swelling of the limbs, increased sleep, CheyneStokes respirations, and hallucinations.
Which of the following indicates the nurse understands the report?
Begin life-saving measures, such as a rapid response call.
Call the provider as these signs and symptoms are abnormal.
Rapid respirations that are unusually deep and regular, and are curative for the patient.
The nurse understands that these are impending signs of death and are normal
The nurse understands that these are impending signs of death and are normal.
The Correct Answer is D
Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Reporting the APs to the charge nurse may seem like an appropriate action, but it does not directly address the conflict. It’s important for the nurse to take an active role in conflict resolution, rather than passing the responsibility to someone else.
Choice B rationale
Allowing the APs to resolve their issues might be a good idea in some situations, but it’s not the best choice here. As a nurse, it’s part of your role to ensure that conflicts are resolved in a way that promotes a positive and productive work environment. By simply allowing the APs to resolve their issues, you’re not taking an active role in conflict resolution.
Choice C rationale
Confronting the APs to discuss their argument is the best choice. This action demonstrates conflict resolution because the nurse is taking an active role in addressing the issue. By discussing the argument with the APs, the nurse can help them understand each other’s perspectives and find a solution that works for everyone.
Choice D rationale
Telling the APs they are acting immaturely is not an effective way to resolve conflict. This approach is likely to escalate the conflict rather than resolve it. It’s important to approach conflicts with a goal of understanding and resolution, rather than placing blame or making judgments.
Correct Answer is A
Explanation
Choice A rationale
Herpes simplex virus encephalitis is a severe condition that requires immediate treatment. The most common medication used for this condition is acyclovir, which is administered intravenously. Acyclovir works by inhibiting the replication of the virus, thereby reducing the severity and duration of the infection.
Choice B rationale
Cyclosporine is an immunosuppressive medication that is often used to prevent organ rejection after transplantation. It is not typically used in the treatment of viral infections such as herpes simplex virus encephalitis.
Choice C rationale
Without specific information about “Medication C”, it’s difficult to provide a rationale.
However, it’s important to note that the treatment of herpes simplex virus encephalitis typically involves antiviral medications, with acyclovir being the most commonly used.
Choice D rationale
Similar to Choice C, without specific information about “Medication D”, providing a rationale is challenging. As mentioned, the standard treatment for herpes simplex virus encephalitis is acyclovir.
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