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 A
Explanation
Explanation:
A. Spirituality decreases feelings of depression:
This statement is generally accurate. Many studies and anecdotal evidence suggest that spirituality can have a positive impact on mental and emotional well-being, including reducing feelings of depression and providing a sense of peace and comfort.
B. Spirituality increases feelings of hopelessness:
This statement is not typically supported by research or clinical observations. Spirituality often fosters feelings of hope, meaning, and purpose, which can counteract feelings of hopelessness commonly experienced by individuals facing end-of-life challenges.
C. Spirituality increases the desire to hasten death:
There is limited evidence to support this statement. In fact, spirituality often provides individuals with a sense of resilience, acceptance, and coping mechanisms that may reduce the desire to hasten death. However, individual beliefs and experiences can vary widely.
D. Spirituality decreases quality of life:
This statement is generally inaccurate. For many individuals, spirituality enhances quality of life by providing a sense of meaning, connection, and comfort, especially during challenging times such as end-of-life care.
Correct Answer is C
Explanation
Explanation:
A. "I will keep my walker at the end of my bed."
Keeping the walker at the end of the bed is generally a good practice for accessibility and mobility support, especially for clients who use walkers to assist with walking. However, this statement alone does not directly address falls prevention strategies or indicate a comprehensive understanding of home safety measures related to falls.
B. "I will place an area rug at the entry of my bathroom."
Placing an area rug at the entry of the bathroom can actually increase the risk of falls rather than prevent them. Area rugs are common tripping hazards, especially in areas where water or moisture may be present (like bathrooms). This statement indicates a potential misunderstanding of falls prevention strategies because it suggests an action that could contribute to falls rather than prevent them.
C. "I will place a bath seat in my shower to use when I bathe."
This statement demonstrates a clear understanding of falls prevention strategies. Placing a bath seat in the shower is a proactive measure to enhance safety during bathing, as it provides stability and reduces the risk of slipping and falling on wet surfaces. Using assistive devices like a bath seat is recommended for individuals with a history of falls or balance issues.
D. "I will keep the fluorescent ceiling light on in my room at night."
Keeping the room well-lit at night is beneficial for falls prevention, as adequate lighting can help individuals see potential hazards and navigate their environment safely. While this statement reflects a general awareness of falls prevention principles related to lighting, it is not as specific or directly related to falls prevention during activities like bathing (as mentioned in option C).
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