A nurse is caring for a client who is at the end of life and is experiencing dyspnea.
Which of the following actions should the nurse take?
Increase the heat in the client's room.
Perform nasotracheal suctioning for the client.
Place the head of the client's bed flat.
Administer an opioid narcotic to the client.
The Correct Answer is D
Choice A rationale:
Increasing the heat in the client's room is not the appropriate action for managing dyspnea. Dyspnea, or difficulty breathing, is not typically related to room temperature. Other interventions should be prioritized.
Choice B rationale:
Performing nasotracheal suctioning for the client is not the initial action to address dyspnea at the end of life. Suctioning is indicated when there is excessive secretions or airway obstruction but should not be the first intervention for dyspnea.
Choice C rationale:
Placing the head of the client's bed flat is not the best action for a client experiencing dyspnea. Elevating the head of the bed (Fowler's position) is the recommended position to improve lung expansion and reduce dyspnea in clients with breathing difficulties.
Choice D rationale:
Administering an opioid narcotic to the client is the most appropriate action for managing dyspnea at the end of life. Opioid medications, such as morphine, are often used to relieve severe dyspnea in hospice and palliative care settings. These medications can help relax the client and reduce the sensation of breathlessness. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating the concept of disease prevention during a blood pressure screening for a client with a family history of hypertension. Disease prevention involves actions taken to reduce the risk of developing a disease or condition. In this case, the nurse is actively screening for hypertension, a condition that the client may be at risk for due to their family history. By identifying elevated blood pressure early, the nurse can help prevent the progression of hypertension and its associated complications.
Choice B rationale:
Holistic health is a comprehensive approach to healthcare that considers the physical, emotional, social, and spiritual aspects of an individual. While holistic health is an essential aspect of nursing care, the scenario described in the question focuses on a specific action related to blood pressure screening, which is better categorized as disease prevention.
Choice C rationale:
Health promotion involves activities that aim to enhance a person's well-being and quality of life, such as encouraging healthy behaviors and lifestyle choices. While blood pressure screening can be a part of health promotion, the primary goal in the scenario is to identify and prevent hypertension, which aligns more with disease prevention.
Choice D rationale:
Health education refers to the process of providing information and education to individuals to help them make informed decisions about their health. While health education may be a part of the overall nursing care provided to the client, the primary action in the scenario is to perform a blood pressure screening, which is a proactive measure to prevent disease, rather than solely focused on educating the client.
Correct Answer is B
Explanation
Choice A rationale:
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
Choice C rationale:
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
Choice D rationale:
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Choice B rationale:
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
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