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 B
Explanation
Choice A rationale
Carbonic anhydrase inhibitors are not typically the first line of treatment for glaucoma. They work by decreasing the production of eye fluid, but they are usually used when other treatments have not been successful. Choice B rationale
Prostaglandin analogs, such as latanoprost and travoprost, are often the first line of treatment for glaucoma. They work by increasing the outflow of eye fluid to lower pressure in the eye.
Choice C rationale
Alpha-agonists are not typically the first line of treatment for glaucoma. They work by both decreasing the production of eye fluid and increasing its outflow, but they are usually used when other treatments have not been successful.
Choice D rationale
Beta-blockers, like timolol, are sometimes used as initial treatment for glaucoma, but they are not typically the preferred initial medication. They work by reducing the production of eye fluid.
Correct Answer is A
Explanation
Choice A rationale
For a client with Parkinson’s disease who has difficulty swallowing or chewing due to muscle rigidity, semi-solid food with thick liquids can be easier to swallow and reduce the risk of choking.
Choice B rationale
Minced foods and fluid restriction may not provide the necessary nutrients and hydration for a client with Parkinson’s disease.
Choice C rationale
A low-residue diet, which is low in fiber, may not be appropriate for a client with Parkinson’s disease, as constipation is a common symptom of the disease and fiber can help alleviate this.
Choice D rationale
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. It is typically reserved for clients who cannot or should not get their nutrition through eating.
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