A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?
Direct the partner to leave and return once postmortem care is complete.
Instruct the partner not to touch the client’s body.
Place the client’s personal belongings in a safe location in the facility.
Ask the partner about any rituals they would like to be performed.
The Correct Answer is D
Choice A reason: Directing the partner to leave and return once postmortem care is complete is not respectful of the partner's feelings and wishes. The nurse should allow the partner to stay and participate in the postmortem care if they desire.
Choice B reason: Instructing the partner not to touch the client’s body is not compassionate or supportive of the partner's grief. The nurse should encourage the partner to touch, hold, or kiss the client’s body as a way of saying goodbye.
Choice C reason: Placing the client’s personal belongings in a safe location in the facility is a necessary action, but not the priority. The nurse should first ask the partner if they want to keep any of the belongings or give them to the nurse for safekeeping.
Choice D reason: Asking the partner about any rituals they would like to be performed is the most appropriate action. The nurse should respect and facilitate the partner's cultural, religious, or personal preferences for postmortem care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increased convex curve of the cervical spine is not an indication of scoliosis, but of kyphosis. Kyphosis is a condition that causes a forward rounding of the upper back, resulting in a hunched posture.
Choice B reason: Increased concave curve of the thoracic spine is not an indication of scoliosis, but of lordosis. Lordosis is a condition that causes an excessive inward curvature of the lower back, resulting in a swayback posture.
Choice C reason: Expansion of the upper intercostal spaces is not an indication of scoliosis, but of emphysema. Emphysema is a lung disease that causes the air sacs to become damaged and enlarged, resulting in difficulty breathing and a barrel chest.
Choice D reason: Unequal height of the shoulders is an indication of scoliosis. Scoliosis is a condition that causes a sideways curvature of the spine, resulting in an asymmetrical appearance of the shoulders, hips, and waist.
Correct Answer is B
Explanation
Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.
Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.
Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.
Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.
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