A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?
Moist mucous membranes
Tachycardia
Irregular respirations
Hypertension
The Correct Answer is C
Explanation:
A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.
B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.
C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.
D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation:
A. Have a pen and paper.
Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.
Correct Answer is D
Explanation
Explanation:
A. Incorporate the treatment into the client's care:
Once the nurse has determined whether the client's grieving is healthy or complicated, they can integrate appropriate treatments and interventions into the client's care plan. Treatment options may include counseling, therapy, support groups, medication (if indicated), and holistic approaches to address physical, emotional, and spiritual aspects of grief.
B. Develop client-specific goals and outcomes:
Collaborating with the client, the nurse establishes client-specific goals and outcomes related to grief management and coping. These goals should be realistic, measurable, and aligned with the client's needs and preferences. Examples of goals may include improving coping skills, reducing emotional distress, fostering acceptance, and promoting resilience.
C. Determine whether coping strategies were successful:
Throughout the care process, the nurse continuously evaluates the effectiveness of coping strategies implemented to support the client in managing grief. Assessment of coping strategies involves monitoring the client's emotional state, functional status, coping skills utilization, and progress toward achieving established goals and outcomes. Adjustments to the care plan may be made based on the assessment findings.
D. Establish whether the client's grieving is healthy or complicated:
This step involves assessing the client's grief to determine whether it is a normal, healthy response to loss or if it has become complicated, characterized by intense, prolonged, or dysfunctional grief reactions. Assessing the client's grief status is crucial for tailoring appropriate interventions and support.
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