A nurse is visiting a client in the home to assess for potential safety risks. Which of the following findings would the nurse identify as being risks to the client's safety? (Select all that apply)

High gloss floors

Multiple ceiling lights

Extension cords across hallway

Grab bar in the shower

Answer and Explanation

Correct Answer : A,C

A. High gloss floors can be slippery, increasing the risk of falls, especially if wet or not maintained properly.
B. Multiple ceiling lights do not inherently pose a safety risk; adequate lighting is generally beneficial for safety.
C. Extension cords across hallways are a tripping hazard and pose a significant risk for falls.
D. A grab bar in the shower is a safety feature designed to prevent falls and assist with stability, not a risk.

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Correct Answer is B

Explanation

A. "You don't need to worry about the client as this is a normal sign of dying." This is not appropriate. While loss of appetite can be a normal part of the dying process, the family may need support and reassurance.
B. “This can often lead to a sense of peacefulness for the client.” This is appropriate. Refusal to eat can be a natural part of the end-of-life process, and it can help the client achieve comfort and a sense of peace.
C. "Let's try to plan a schedule for giving the client high-calorie liquids." This is not appropriate. Forcing or scheduling feeding can be counterproductive and may not align with the client's comfort or preferences at the end of life.
D. “I can get a prescription for a feeding tube if you think this would be okay with the client.” This is not appropriate. At the end of life, a feeding tube may not be in the client's best interest and may not contribute to their comfort. It is important to focus on palliative care rather than invasive interventions.

A. "We recommend that you sit at your parent's bedside so you can document the time of death." B. "Limit the amount of environmental noise in your parent's room to decrease stimulation." C. "This may be very difficult for you to watch your parent, so take some respite time to re-charge." D. "Family often uses this time to tell their parent that it is okay to let go."

Correct Answer is B

Explanation

A. Documenting the time of death is not an immediate concern during the process of terminal delirium and does not directly address the patient's comfort.
B. Limiting environmental noise helps reduce stimulation, which can be beneficial for a patient experiencing terminal delirium and unresponsiveness, helping to maintain a calm environment.
C. While taking respite time may be necessary for family members, it does not directly address the needs of the patient with terminal delirium.
D. Telling the patient it is okay to let go is emotionally supportive but does not address the immediate need to manage symptoms and provide comfort during terminal delirium.

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A nurse is visiting a client in the home to assess for potential safety risks. Which of the following findings would the nurse identify as being risks to the client's safety? (Select all that apply)

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