A nurse is providing teaching about palliative care to the family of a client who is approaching death. Which of the following information should the nurse include in the teaching?
Awaken the client frequently throughout the day.
Keep the client warm by applying an electric blanket.
Position the client on their side with the head of bed elevated.
Encourage the client to eat soft foods intermittently.
The Correct Answer is C
Choice A rationale:
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
Choice B rationale:
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
Choice C rationale:
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
Choice D rationale:
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Correct Answer is A
Explanation
Choice A rationale:
Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.
Choice B rationale:
Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.
Choice C rationale:
Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.
Choice D rationale:
Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.
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