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 A
Explanation
Choice A reason: A sweat chloride content of 85 mEq/L is indicative of cystic fibrosis, as normal values are below 30 mEq/L, and values above 60 mEq/L are diagnostic for cystic fibrosis.
Choice B reason: Hard, packed stools could be a sign of cystic fibrosis but are not as diagnostic as a sweat chloride test.
Choice C reason: Increased blood levels of fat-soluble vitamins are not typically associated with cystic fibrosis; patients often have deficiencies due to malabsorption.
Choice D reason: A chest x-ray negative for atelectasis does not indicate cystic fibrosis, as atelectasis can be present in many conditions.
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