A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?
Encourage the family to involve siblings when caring for the child.
Reinforce with the family that they should avoid discussing death with the child.
Collect vital signs every 2 hr as the child's condition deteriorates.
Perform passive range of motion to the child's extremities every 4 hr.
The Correct Answer is A
A. Encouraging the family to involve siblings in the care of the terminally ill child is important for fostering family support, allowing siblings to understand the situation, and promoting emotional bonding.
B. Avoiding discussions about death is not recommended. It is important to communicate with the child about death in an age-appropriate manner to help them understand and cope with the situation.
C. While monitoring vital signs is important, it is not the most therapeutic intervention in the final stages of terminal illness. Comfort care, including pain management and emotional support, takes priority.
D. Passive range of motion is not essential for a child in the final stages of terminal illness unless necessary for specific comfort or mobility needs. Care should focus on comfort measures rather than routine interventions.
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Related Questions
Correct Answer is A
Explanation
A. The new onset of lethargy in a child with endocarditis is a significant concern, as it can indicate worsening infection or complications such as embolism. This child requires urgent assessment to prevent further deterioration.
B. Erythema of the lips in a child with Kawasaki disease is concerning, but this symptom is expected as part of the disease process. However, other signs like fever and conjunctivitis would be more concerning.
C. An increased erythrocyte sedimentation rate (ESR) in a child with rheumatic fever suggests inflammation, but it is not an immediate life-threatening concern like the lethargy in endocarditis.
D. Weak pedal pulses in a toddler with coarctation of the aorta indicate circulatory compromise, but this child may not be in immediate danger as the condition is often diagnosed and managed with interventions like surgery or medication.
Correct Answer is B
Explanation
A. Passive range-of-motion exercises should be performed to prevent complications like contractures, but they should be done as ordered by the provider, not automatically every 2 hours.
B. Applying protective padding to the end of the pin sites helps prevent pressure injuries and irritation, which is a key part of maintaining skin integrity and preventing infection.
C. There is no indication that fiber intake should be reduced. In fact, a high-fiber diet is encouraged to prevent constipation, which is a common complication for immobile patients.
D. The traction weights should not be lifted off the floor, as this could interfere with the traction setup and the healing process. Traction should be maintained properly to align and stabilize the fracture.
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