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 ["A","B","D","E"]
Explanation
Choice A rationale
As people age, the stiffness of the arterial system increases, leading to left ventricle hypertrophy, increased afterload on the left ventricle, and an increase in systolic blood pressure. This is a physiological change that occurs with aging.
Choice B rationale
With aging, the number of cells in the kidneys decreases markedly, which can affect the functioning of the urinary tract, including the bladder. This can lead to a reduced bladder capacity.
Choice C rationale
This statement is incorrect. As people age, they often experience a decrease in visual acuity and an increased sensitivity to glare. This can make it more difficult for older adults to see, especially in brightly lit environments.
Choice D rationale
Dehydration of intervertebral discs is a common occurrence with aging. This can lead to a decrease in height and changes in the curvature of the spine.
Choice E rationale
As people age, their cough reflex can become reduced. This can increase the risk of aspiration and pneumonia, especially in individuals with other health conditions that affect swallowing.
Correct Answer is A
Explanation
Choice A rationale
This response shows empathy and understanding towards the patient’s situation. It acknowledges the patient’s craving for strawberry ice cream and offers a compromise that aligns with the patient’s dietary restrictions.
Choice B rationale
This response may come across as insensitive and dismissive of the patient’s feelings. It’s important to show empathy and understanding when dealing with patients, especially those in hospice care.
Choice C rationale
This response may not be appropriate as it does not consider the patient’s dietary restrictions. While it shows empathy, it’s important to respect and adhere to the patient’s dietary needs.
Choice D rationale
This response may not be appropriate as it does not address the patient’s statement. It’s important to acknowledge and respond to the patient’s feelings and concerns.
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