A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

"We can discuss this after completing the admission process."

"Your partner is experiencing an expected response to the dying process."

"Your partner is in the denial stage of grief."

"You should discuss this problem with your family members."

Answer and Explanation

The Correct Answer is B

A. "We can discuss this after completing the admission process.": This dismisses the partner’s concern and ignores a valuable opportunity for emotional support.

B. "Your partner is experiencing an expected response to the dying process.": Verbal aggression is often a manifestation of the Anger stage of grief (Kübler-Ross) or can be related to terminal restlessness/delirium. Normalizing this helps the partner understand the behavior.

C. "Your partner is in the denial stage of grief.": While they may be in a stage of grief, aggression is typically associated with Anger, not Denial.

D. "You should discuss this problem with your family members.": This avoids the nurse's responsibility to provide education and support to the family during hospice admission.

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Correct Answer is C

Explanation

A. "Take a 1-hour nap each day.": Napping during the day, especially for an hour, can interfere with the ability to fall asleep and stay asleep at night.

B. "Watch television in bed.": The bed should be used only for sleep and intimacy. Watching TV provides "blue light" and mental stimulation that disrupts the circadian rhythm.

C. "Drink a glass of milk before bedtime.": Milk contains L-tryptophan, an amino acid that serves as a precursor to serotonin and melatonin, which helps induce sleep.

D. "Take a long walk before bedtime.": Vigorous exercise shortly before bed increases core body temperature and heart rate, which can make falling asleep more difficult.

A. Apply a heating pad to the client's neck. B. Offer the client a warm beverage. C. Provide the client with dry clothing. D. Wrap the client in warm blankets.

Correct Answer is C

Explanation

A. Apply a heating pad to the client's neck.: This is an intervention, but not the priority. Rapid external rewarming can sometimes cause "rewarming shock."

B. Offer the client a warm beverage.: This is helpful but is not the priority action for someone with acute exposure.

C. Provide the client with dry clothing.: According to the Nursing Process, the first priority is to stop the loss of body heat. Wet clothing loses heat 25 times faster than dry clothing; removing it is the most immediate way to stabilize the client.

D. Wrap the client in warm blankets.: This is done after removing wet clothing to begin the rewarming process.

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A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

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