A nurse is caring for a client who is near death. Which of the following actions should the nurse take?
Administer scheduled pain medications.
Provide oral care every 6 hr.
Administer liquids using a syringe.
Whisper when talking to family members.
The Correct Answer is A
A. Administer scheduled pain medications is appropriate because providing comfort is a priority in end-of-life care. Administering scheduled pain medications helps alleviate any discomfort or pain the client may be experiencing.
B. Providing oral care every 6 hr may not be necessary in the end-of-life stage, as the client's ability to tolerate oral care may decrease, and excessive oral care may cause discomfort.
C. Administering liquids using a syringe may not be appropriate if the client is unable to swallow or if there are concerns about aspiration.
D. Whispering when talking to family members is not necessary; instead, the nurse should communicate in a calm and clear manner, adjusting the volume and tone as needed to accommodate the client's condition and preferences.
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Related Questions
Correct Answer is C
Explanation
A. Incorrect. While proper spacing of infant bassinets is important for infection control, this specific distance (24 inches) may not be universally applicable and may vary depending on the facility's protocols.
B. Incorrect. Alcohol-based hand rubs are recommended for hand hygiene in healthcare settings, as they are effective against a broad range of pathogens. They should not be avoided unless contraindicated due to specific circumstances.
C. Correct. Visitors with upper respiratory infections can spread respiratory viruses to vulnerable newborns, so wearing a mask can help prevent transmission.
D. Incorrect. Pumped breastmilk can typically be left at room temperature for a shorter duration, usually up to 4 hours, to maintain its safety and quality.
Correct Answer is B
Explanation
A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.
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