A nurse is caring for a client who is at the end of life and is unresponsive.
Which of the following actions should the nurse take?
Continue to talk to the client as if they are awake.
Limit the client's visitors to one at a time.
Avoid touching the client.
Whisper when talking in the client's room.
The Correct Answer is A
Choice A rationale:
When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.
Choice B rationale:
Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.
Choice C rationale:
Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.
Choice D rationale:
Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Health education involves providing information and knowledge to clients to help them make informed decisions about their health. It focuses on teaching individuals about health-related topics. In this scenario, the nurse is not engaged in health education but rather in blood pressure screening, which is a form of health assessment and monitoring.
Choice B rationale:
Health promotion involves activities that encourage and empower individuals to take control of their health and well-being. It aims to enhance the overall health of the population. While blood pressure screening is a preventive measure, it does not encompass the broader concept of health promotion. It is more specific to early detection and monitoring of health conditions.
Choice C rationale:
Holistic health refers to an approach that considers the physical, emotional, social, and spiritual aspects of an individual's well-being. It recognizes the interconnectedness of these aspects and seeks to address them in a comprehensive manner. Performing a blood pressure screening, while important, is a specific health assessment task and does not fully encompass the holistic health approach.
Choice D rationale:
Disease prevention involves activities and measures taken to reduce the occurrence and impact of specific diseases. In this scenario, the nurse is performing a blood pressure screening for a client with a family history of hypertension. This screening is a preventive measure aimed at detecting and preventing the development of hypertension, which falls under the category of disease prevention. By identifying clients at risk, healthcare providers can intervene early and implement strategies to prevent or manage the condition. .
Correct Answer is B
Explanation
Choice A rationale:
Reduced respiratory rate is not a typical manifestation of pain. In fact, pain often leads to an increased respiratory rate as the body responds to discomfort by trying to minimize it.
Choice B rationale:
Elevated blood pressure is a common manifestation of pain. When a person experiences pain, their sympathetic nervous system is activated, leading to an increase in heart rate and blood pressure. This response is designed to prepare the body to fight or flee from a potential threat, and it helps redirect blood flow to vital organs.
Choice C rationale:
Constricted pupils are not a direct manifestation of pain. In contrast, dilated pupils can be seen in response to pain as a result of sympathetic nervous system activation.
Choice D rationale:
Decreased heart rate is not typically associated with pain. Pain tends to increase heart rate as a part of the body's stress response.
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