A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?
Place the client in a supine position
Remind the client to eat scheduled meals daily.
Offer the client a blanket to keep warm.
Speak in a loud tone when addressing the client
The Correct Answer is C
A. Place the client in a supine position. As clients near the end of life, the supine position may compromise breathing. A semi-Fowler’s or lateral position is usually preferred to promote comfort and respiratory ease.
B. Remind the client to eat scheduled meals daily. At the end of life, appetite typically decreases, and forcing food can cause discomfort. Nutrition should be offered based on the client's desire, not forced on a strict schedule.
C. Offer the client a blanket to keep warm. Clients nearing death often experience peripheral circulation decline, leading to feelings of coldness. Providing a blanket promotes comfort and warmth without being invasive.
D. Speak in a loud tone when addressing the client. Loud speech can be disorienting and distressing, especially if the client is already weak or confused. Use a calm, clear, and gentle tone to provide comfort and maintain dignity.
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Related Questions
Correct Answer is D
Explanation
A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.
Correct Answer is C
Explanation
A. Apply splints to the child's extremities during the day. Splints are typically used at night to help prevent joint contractures and support proper alignment during rest. Daytime use may limit mobility and physical activity, which are encouraged.
B. Encourage the child to take naps during the day. While rest is important, excessive daytime napping can contribute to joint stiffness and reduced function. Activity and movement are encouraged to maintain joint flexibility.
C. Have the child take a tub bath each morning. Warm baths help relieve joint stiffness and pain associated with juvenile idiopathic arthritis. Morning bathing is especially beneficial to improve mobility at the start of the day.
D. Keep the child on bedrest as long as pain persists. Prolonged bedrest can lead to muscle atrophy, stiffness, and joint contractures. Maintaining activity, as tolerated, is key to managing symptoms and preserving joint function.
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