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

The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.

a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.

b) Placing the client in a supine position is not necessary and may not be comfortable for the client.

c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.

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Correct Answer is C

Explanation

Echolalia is the repetition of words or phrases spoken by others. In this case, the client is repeating the nurse's question, "How are you?" This is an example of echolalia.

a) "I am lovistrated" is an example of neologism, which is the creation of new words.

b) "Super, trooper, and duper" is an example of clang association, which is the use of words that sound alike but have no logical connection.

d) "Pink spots in Africa" is an example of a thought disorder, which is a disruption in the organization and expression of thoughts.

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

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

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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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