A nurse is caring for a client who is receiving hospice care in the home. The family asks, "how will we know when death is near?" The nurse should inform the family that which of the following signs indicates that death is approaching? (Select all that apply.)
Confusion and restlessness.
Increased appetite and thirst.
Increase in urinary and bowel output.
Increased fatigue and sleep.
Excess secretions in the throat and decrease swallow reflex.
Correct Answer : A,D,E
A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.
B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.
In fact, clients often have decreased appetite and thirst as the body's systems slow down.
C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.
D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.
E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.
B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.
C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.
D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.
E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.
Correct Answer is B
Explanation
A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.
B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.
C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.
D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.
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