A nurse is caring for a client who has just died. Which of the following actions should the nurse take?
Leave noninvasive equipment on the client's body.
Remove the client's dentures.
Turn the lights up in the client's room.
Close the client's eyes before the family views the body.
None
None
The Correct Answer is D
A. Leaving noninvasive equipment on the client’s body is not appropriate during postmortem care. Tubing and devices should be removed unless an autopsy is required.
B. Dentures should generally be left in place to maintain the natural shape of the face and promote a more normal appearance for family viewing.
C. Turning the lights up is unnecessary and may create a harsh environment. A calm, respectful setting with normal or dim lighting is preferred during postmortem care.
D. Closing the client’s eyes before the family views the body helps provide a peaceful and dignified appearance and is an important part of postmortem care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.
B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.
C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.
D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.
Correct Answer is B
Explanation
A. Encourage the client to soak in a hot bath.: While a warm bath can help alleviate muscle tension and discomfort, it is not recommended during the latent phase of labor due to the potential for increasing the risk of infection, especially if the membranes are ruptured.
B. Instruct the client to change positions frequently.: Frequent position changes during the latent stage of labor can help alleviate pelvic pain, improve comfort, and encourage progress in labor. This is a beneficial intervention that promotes movement and comfort without introducing unnecessary risks.
C. Apply fundal pressure during contractions.: Fundal pressure is not appropriate during the latent stage of labor, as it can cause fetal distress or other complications. It is typically avoided unless indicated in more advanced stages of labor under specific circumstances.
D. Tell the client to push during contractions.: Pushing is not recommended during the latent stage of labor. The latent phase involves the cervix gradually dilating, and pushing should be delayed until the active stage of labor when the cervix is fully dilated and ready for delivery.
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