A nurse is visiting with the family of a client who has just died. Which of the following actions should the nurse take to promote comfort for the family?

Allow the family as much time as they want with the client.

Use paper tape to hold the client's eyelids open.

Place the client in a supine position.

Avoid repeating information about the client's death.

Answer and Explanation

The Correct Answer is A

A. Allowing the family as much time as they want with the client is essential for them to process their emotions, say goodbye, and find closure. This respects their grieving process and allows
them to spend precious moments with their loved one.

B.   Using paper tape to hold the client's eyelids open is not appropriate and may cause discomfort or distress to the family.

C.   Placing the client in a supine position is unnecessary after death and may not contribute to the family's comfort.
D.   Avoiding repeating information about the client's death is not advisable. The nurse should be available to provide clarification, answer questions, and offer support as needed.

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Correct Answer is B

Explanation

A. Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B. Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C. Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D. While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 0 to 10.

Correct Answer is B

Explanation

A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.

D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.

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A nurse is visiting with the family of a client who has just died. Which of the following actions should the nurse take to promote comfort for the family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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