Exhibits
Complete the following sentence by using the list of options.
Mrs. Thompson is at high risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.
Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.
Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.
Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.
Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.
Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.
End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encourage the family's expression of their feelings. The father’s statement reflects emotional shock and denial, which are common initial reactions to devastating news. Encouraging the family to express their emotions helps them begin processing their grief and provides emotional support during a difficult time. Active listening and validating their feelings are essential first steps in therapeutic communication.
B. Explore effective ways of family coping. Assessing how the family copes with stress is important, but it is not the immediate priority when the father is in emotional distress. Before discussing coping strategies, the nurse should first provide a safe space for emotional expression.
C. Instruct the family about anticipatory grieving. While anticipatory grieving education is important, the father is still in the early stages of shock and numbness. Addressing grief education too soon may feel overwhelming. The nurse should first focus on emotional support.
D. Discuss the disease and its manifestations with family members. Providing information about the disease is important for understanding what to expect, but at this moment, the father is struggling with his emotions. Education should be provided gradually, once the family is emotionally ready to process medical information.
Correct Answer is C
Explanation
A. Review the patient's medical history for past pain management interventions and their outcomes. While reviewing past pain management strategies can provide useful context, it does not directly assess the patient's current pain experience. A real-time, comprehensive pain assessment is necessary before determining an appropriate intervention.
B. Observe the patient's facial expressions and body language for signs of discomfort. Nonverbal cues can help assess pain, particularly in non-communicative patients. However, pain perception is subjective, and self-reporting is the most reliable method for assessing pain intensity, location, and characteristics.
C. Ask the patient to describe the pain using a pain scale and provide details about its location, duration, and intensity. A comprehensive pain assessment involves gathering subjective information directly from the patient. Using a pain scale and asking about the pain's location, duration, and intensity ensures a clear understanding, which helps guide appropriate pain management interventions.
D. Measure the patient's vital signs and note any changes. Changes in vital signs, such as increased heart rate or blood pressure, may indicate pain but are not specific or reliable indicators. Pain assessment should primarily rely on the patient’s report, supplemented by objective findings when necessary.
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