A nurse is explaining the early stage of the dying process to a patient’s family.
A family member mentions, “My parent seems really confused at times.”. What is the most appropriate response from the nurse?
This is a normal cognitive change that is happening.
Your parent is experiencing sundowners.
Your parent might be feeling anxious.
Your parent might need more rest.
The Correct Answer is A
Choice A rationale
Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.
Choice B rationale
Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.
Choice C rationale
While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.
Choice D rationale
Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A patient’s address is indeed an example of personally identifiable information. This statement is correct and does not indicate a need for further teaching.
Choice B rationale
HIPAA is indeed a federal law, not a state law. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
HIPAA did establish regulations of individually identifiable health information in verbal, electronic, or written form. This statement is correct and does not indicate a need for further teaching.
Choice D rationale
Information about a client cannot be disclosed to family members at any time without the client’s consent. This statement indicates a need for further teaching.
Correct Answer is A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
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