An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks how to know that the spouse's death is imminent because their two adult children want to be there when the client dies. Which is the best response by the nurse?
Explain the client will start to lose consciousness and the body systems will slow down.
Offer to discuss the client's health status with each of the adult children.
Gather information regarding how long it will take for the children to arrive.
Reassure the spouse that the healthcare provider will notify when to call the children.
The Correct Answer is A
A. Explaining the physiological signs of imminent death helps prepare the spouse and family for what to expect, allowing them to gather as needed.
B. While discussing the client’s health status may be supportive, it does not directly address the spouse’s request for understanding signs of impending death.
C. Gathering information about how long it will take for the children to arrive is important but secondary to providing the spouse with information about impending signs of death.
D. While reassuring the spouse is important, it may not provide the immediate information they seek about recognizing the signs of dying.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A downward trend in blood pressure and a rapid, irregular pulse may indicate general hemodynamic instability but are not specific to arterial obstruction.
B. A moist and oozing dressing can indicate bleeding but does not directly suggest arterial obstruction.
C. A weaker pulse in the left foot compared to the right foot could indicate a vascular issue but not necessarily arterial obstruction specifically in the right leg.
D. A cool, pale, and blanched right foot indicates compromised blood flow and is a classic sign of arterial obstruction, warranting immediate assessment and intervention.
Correct Answer is A
Explanation
A. Noting the presence of an auscultatory gap is essential, as it may indicate that the blood pressure reading could be inaccurately low if not recognized. This helps ensure the accuracy of the blood pressure measurement.
B. Repositioning the stethoscope may be necessary if the sounds are unclear, but recognizing the potential auscultatory gap should be prioritized first.
C. Re-inflating the cuff may be appropriate if the nurse is unsure about the readings; however, identifying an auscultatory gap is the first step to ensure accurate assessment.
D. Continuing with the blood pressure assessment without acknowledging the silence followed by a Korotkoff sound may lead to misinterpretation of the blood pressure readings.
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