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
Explanation
Choice A rationale
Allowing extra time to communicate with the patient is a crucial action when caring for a patient with impaired speech. This approach respects the patient’s autonomy and ensures that they have the time they need to express themselves.
Choice B rationale
Finishing sentences for the patient can be seen as disrespectful and may lead to frustration. It’s important to allow the patient to communicate at their own pace.
Choice C rationale
While open-ended questions can be useful in some situations, they may be challenging for a patient with impaired speech. It might be more effective to ask yes/no questions or use other communication aids.
Choice D rationale
Visual aids can be very helpful for patients with speech impairments. They can supplement verbal communication and make it easier for the patient to understand and be understood.
Correct Answer is B
Explanation
Choice A rationale
While it’s important for the client to understand the alternatives to the procedure, it’s typically the responsibility of the physician or surgeon to explain these alternatives, not the nurse.
Choice B rationale
One of the nurse’s responsibilities in the informed consent process is to confirm that the client is competent to sign for the procedure. This means ensuring that the client understands the procedure, its risks and benefits, and is making the decision voluntarily.
Choice C rationale
Discussing the risks of the procedure with the client is typically the responsibility of the physician or surgeon, not the nurse.
Choice D rationale
While the nurse may provide some information about what will occur during the procedure, it’s typically the responsibility of the physician or surgeon to provide detailed information about the procedure.
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.