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 B
Explanation
Choice A rationale:
"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.
Choice B rationale:
"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.
Choice C rationale:
"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.
Choice D rationale:
"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.
Correct Answer is C
Explanation
Choice A rationale:
Abstract thinking develops during Piaget's formal operational stage, not the preoperational stage. The preoperational stage is characterized by symbolic thinking and egocentrism but lacks the ability for abstract thought.
Choice B rationale:
Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events, and it does not involve abstract thinking. Abstract thinking, including hypothetical and deductive reasoning, is a feature of the formal operational stage.
Choice C rationale:
Abstract thinking and formal operational thought develop during Piaget's formal operational stage, which typically begins in adolescence and continues into adulthood. This stage is characterized by the ability to think logically, solve complex problems, and consider abstract concepts.
Choice D rationale:
The sensorimotor stage is the earliest stage in Piaget's theory of cognitive development, and it is primarily concerned with sensory and motor exploration. Abstract thinking is not a component of this stage. .
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