The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?
Report any change in urine color.
Maintain in high Fowler's position.
Keep mucous membranes moist.
Record the client's daily weights.
The Correct Answer is C
Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.
Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.
Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.
Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.
Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.
Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.
Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.
Correct Answer is ["A","B","C","D"]
Explanation
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment findings
- Neurological Alert and oriented times 4.
- Cardiovascular WNL.
- Respiratory WNL.
- Gastrointestinal/Genitourinary Voided twice throughout night, urine clear amber in appearance. Reports no dysuria. No bowel movement but the client is passing gas.
- Integumentary 4 abdominal incisions from laparoscopic procedure sealed with surgical glue. No drainage, redness, or edema present.
- Musculoskeletal Reported chronic knee pain. 5+ strength in bilateral upper extremities, 5+ strength in bilateral lower extremities.
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