A nurse is caring for a child who is dying. Which of the following are findings of impending death? (Select all that apply.)
Sensation of being cold
Heightened sense of hearing
Difficulty swallowing
Tachycardia
Cheyne-Stokes respirations
Correct Answer : A,C,D,E
Choice A reason: A sensation of being cold can occur as the body's circulation diminishes and blood flow to the extremities decreases.
Choice B reason: A heightened sense of hearing is not typically a sign of impending death; this choice is incorrect.
Choice C reason: Difficulty swallowing can be a sign of impending death due to the body's muscles weakening and a decrease in reflexes.
Choice D reason: Tachycardia may occur as the heart tries to compensate for decreased function in other systems.
Choice E reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing, are a common sign of impending death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.
Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.
Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.
Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.
Correct Answer is B
Explanation
Choice A reason: Administering an antidiuretic would be counterproductive in the treatment of a UTI as it would decrease urine output, potentially allowing bacteria to remain in the urinary tract.
Choice B reason: Encouraging frequent voiding helps to flush out bacteria from the urinary tract, which is beneficial in the management of a UTI.
Choice C reason: While evaluating a child's self-esteem is important, it is not directly related to the care of a child with a UTI.
Choice D reason: Restricting fluids is not advisable for a UTI as it would reduce urine flow and hinder the flushing out of bacteria.
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