A nurse is reinforcing teaching with a guardian about manifestations of the impending death of a child. Which of the following manifestations should the nurse include?
Urinary frequency
Difficulty swallowing
Decreased sleep
Increased senses
The Correct Answer is B
Rationale:
A. Urinary frequency: As death approaches, urinary output typically decreases due to reduced kidney perfusion. Urinary frequency is not a common sign of impending death and may suggest other unrelated conditions.
B. Difficulty swallowing: Difficulty swallowing is a common manifestation of impending death. As muscle tone declines, the child may struggle to manage secretions or food, increasing the risk of aspiration and signaling the body is shutting down.
C. Decreased sleep: Clients nearing death often exhibit increased sleep or lethargy, not decreased sleep. Diminished responsiveness and longer periods of unresponsiveness are expected in the final stages of life.
D. Increased senses: Sensory function generally declines as death nears. Vision, hearing, taste, and touch may all diminish, and the child may become less responsive to external stimuli. Increased senses are not expected at this stage
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. A client who has narcissistic personality disorder and refuses to be alone in their room: Clients with narcissistic personality disorder typically display a need for admiration and may fear abandonment, but they are not at increased risk for physical injury.
B. A client who has social anxiety disorder and refuses to attend group therapy: Avoidance of social settings is a hallmark of social anxiety disorder. While it may lead to isolation, it does not place the client at increased risk for physical injury.
C. A client who has bipolar disorder and exhibits impulsive behaviour: Impulsivity during manic episodes in bipolar disorder can lead to high-risk activities such as reckless driving, substance use, or unsafe sexual behavior. These behaviors significantly elevate the client’s risk for accidental or intentional physical injury.
D. A client who has panic disorder and exhibits paresthesia: Paresthesia, such as tingling or numbness, is a common symptom during panic attacks but does not directly increase the risk for physical injury. While distressing, it typically resolves and is not associated with unsafe behaviors.
Correct Answer is B
Explanation
Rationale:
A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.
B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.
C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.
D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.
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