An adult male was diagnosed with stage IV lung cancer three weeks ago.
His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.
Which is the best response by the nurse?
Gather information regarding how long it will take for the children to arrive.
Explain that 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.
Reassure the spouse that the healthcare provider will notify when to call the children.
The Correct Answer is B
Choice B rationale:
Explaining that the client will start to lose consciousness and the body systems will slow down is the best response. This is a common pattern in the dying process, and it provides the wife with a clear and compassionate explanation of what to expect as her husband's death approaches.
Choice A rationale:
Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.
Choice C rationale:
Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.
Choice D rationale:
Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring blood pressure is a general health assessment measure and may not directly contribute to pain relief in a client with migraine headaches. While it's essential to manage blood pressure as part of overall health, this choice does not address the client's specific request for pain relief.
Choice B rationale:
Taking a few days off work may provide some relief from external stressors, but it is not a reliable intervention for migraine pain relief. Migraine management typically involves strategies that directly target headache symptoms.
Choice C rationale:
Learning muscle relaxation techniques can be helpful in managing migraine headaches. Relaxation techniques, such as progressive muscle relaxation, can reduce muscle tension and help alleviate headache symptoms. However, it may not be the highest-priority intervention.
Choice D rationale:
Lying down in a dark, quiet room is the most appropriate intervention for obtaining pain relief from a migraine headache. This approach minimizes sensory stimuli, reduces external factors that may exacerbate the headache, and promotes relaxation. It is a well-established non-pharmaceutical method for managing migraine pain.
Correct Answer is B
Explanation
Choice A rationale:
Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.
Choice B rationale:
Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.
Choice C rationale:
Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.
Choice D rationale:
Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.
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