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","C"]
Explanation
Choice A reason: Increased urinary output is not typically associated with heart failure. In fact, reduced urinary output may be expected due to decreased kidney perfusion.
Choice B reason: Nasal flaring is a sign of respiratory distress and can be expected in infants with heart failure as they struggle to maintain oxygenation.
Choice C reason: Peripheral edema is a common finding in heart failure due to fluid retention and poor circulation.
Choice D reason: Bradycardia is not a typical sign of heart failure in infants; tachycardia is more common. However, bradycardia can occur in advanced stages due to poor cardiac output.
Choice E reason: Cool extremities are indicative of poor perfusion, which is a consequence of decreased cardiac output in heart failure.
Correct Answer is A
Explanation
Choice A reason: A blood creatinine level of 1.3 mg/dL is elevated for a school-age child and indicates impaired kidney function, which is a concern in acute glomerulonephritis.
Choice B reason: A urine output of 550 mL in 24 hours is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
Choice C reason: A blood pressure of 100/74 mm Hg is within the normal range for a school-age child and does not indicate an immediate concern.
Choice D reason: A BUN level of 8 mg/dL is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
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