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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Explanation
Rationale:
- Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
- Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
- Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
- Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
- Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.
Correct Answer is A
Explanation
A. Instill erythromycin ointment into the newborn's eyes: Erythromycin ophthalmic ointment is routinely applied to all newborns to prevent ophthalmia neonatorum, a serious eye infection caused by exposure to Neisseria gonorrhoeae during birth.
B. Give oral sulfadiazine to the mother prior to delivery: Sulfonamides are not recommended for gonorrhea treatment in laboring clients and are ineffective in preventing neonatal eye infections.
C. Administer penicillin G procaine IM to the newborn: Penicillin is used to treat confirmed neonatal infections, not as a routine prophylaxis against gonococcal eye infections.
D. Apply miconazole vaginal cream to the mother prior to delivery: Miconazole is an antifungal used for vaginal yeast infections and has no effect on gonorrhea, so it is not indicated for preventing neonatal infection.
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