A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which the following interventions should the nurse include?
Remind the client to eat scheduled meals daily.
Place the client in a supine position.
Offer the client a blanket to keep warm.
Speak in a loud tone when addressing the client.
The Correct Answer is C
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.
B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.
C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.
D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.
Correct Answer is B
Explanation
Rationale:
A. Choose high-fat cheese as a meat substitute: Cheese is an animal-derived product and not part of a vegan diet. Additionally, it is high in saturated fat, which can contribute to cardiovascular risk.
B. Choose foods high in vitamin B12: Vitamin B12 is primarily found in animal products, so vegans are at risk for deficiency. Including fortified foods or supplements helps prevent anemia and neurological complications.
C. Limit intake of foods high in vitamin C: Vitamin C-rich foods are beneficial for overall health and can improve non-heme iron absorption from plant sources. There is no reason to limit these foods in a vegan diet.
D. Limit intake of nuts and legumes: Nuts and legumes are excellent plant-based sources of protein, healthy fats, and micronutrients. Restricting them would reduce the nutritional adequacy of a vegan diet.
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