A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Completion of an incident report.

Name of the nurse certifying the client's death.

Release of personal belongings form.

One client identifier at the client's time of death.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Release of personal belongings form.

Choice A rationale:

Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.

Choice B rationale:

While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.

Choice C rationale:

The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.

Choice D rationale:

Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.

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Correct Answer is A

Explanation

The correct answer is choice A: "Perform muscle relaxation before bedtime."

Choice A rationale:

Suggesting to the client to "Perform muscle relaxation before bedtime" is a helpful recommendation. Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help calm the body and mind, making it easier to fall asleep.

Choice B rationale:

Advising the client to "Exercise vigorously 1 hour prior to going to bed" is not recommended. Vigorous exercise close to bedtime can actually stimulate the body and make it harder to fall asleep. Gentle, non-strenuous activities are more suitable before bedtime.

Choice C rationale:

Recommending the client to "Drink a cup of hot chocolate at bedtime" is not ideal. Hot chocolate contains caffeine, which is a stimulant that can interfere with sleep. It's better to avoid caffeine-containing beverages close to bedtime.

Choice D rationale:

Suggesting the client to "Change the time you go to sleep each day" disrupts the body's internal clock and sleep-wake cycle. Maintaining a consistent sleep schedule, even on weekends, helps regulate the body's natural sleep patterns.

A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning, It hurts too much." D. "I don't want to take my medicine. It makes me sick to my stomach.”

Correct Answer is B

Explanation

The correct answer is choice B: "Please don't tell my doctor, but I am taking my partner's oxycodone."

Choice B rationale:

This statement presents an ethical dilemma as it reveals the client's engagement in potentially harmful and illegal behavior – taking a controlled substance prescribed for someone else. The nurse must balance the duty to respect the client's confidentiality with the responsibility to address potential harm to the client and others involved.

Choice A rationale:

"I might file a lawsuit because of how my surgery went" does not present an ethical dilemma, but rather a legal concern. While the nurse should listen to the client's complaints and provide appropriate support, this statement is more related to the client's dissatisfaction with their medical care.

Choice C rationale:

"Please don't get me out of bed this morning, It hurts too much" reflects a client's pain management request. While pain management is important, this statement doesn't raise an ethical dilemma on its own. It's within the scope of care to address pain and comfort concerns.

Choice D rationale:

"I don't want to take my medicine. It makes me sick to my stomach" highlights a client's concern about medication side effects. While addressing medication concerns is essential, this statement doesn't inherently pose an ethical dilemma.

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A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

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