A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?

"Encourage your partner to eat three large meals each day.”.

"Opioids will be restricted if your partner develops respiratory distress.”.

"We will use an electric blanket to keep your partner warm.”.

"Assume your partner can hear you, even if they do not respond.”. .

Answer and Explanation

The Correct Answer is D

Choice A rationale

Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.

Choice B rationale

Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.

Choice C rationale

Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.

Choice D rationale

Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.

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Correct Answer is A

Explanation

Choice A rationale

Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.

Choice B rationale

Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.

Choice C rationale

Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.

Choice D rationale

Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.

A. "I think about my grandfather's farm to reduce pain.”. B. "I listen to my favorite music to take my mind off the pain.”. C. "I use focused breathing to control my pain.”. D. "I learn to notice the sensation of muscle tension.”.

Correct Answer is A

Explanation

Choice A rationale

Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.

Choice B rationale

Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.

Choice C rationale

Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.

Choice D rationale

Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.

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A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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