The nurse assesses a terminally ill client who is nearing death. The client's wife expresses concern that he has no appetite and eats very little.
How should the nurse best respond?
Teach the client's wife about the risk of aspiration and explain that loss of appetite is expected when a client nears death.
Request that the health care provider order a dietary nutrition consult to include the client's preferred foods.
Keep fluids and finger foods at the bedside for easy access whenever the client needs them.
Encourage the client's wife to feed the client as much as he will take to maintain adequate nutrition.
The Correct Answer is A
This scenario involves end of life care and ethical communication regarding physiological changes during the dying process. Knowledge of palliative care principles and the natural slowing of metabolic processes is required to address the family's concerns and provide reassurance.
Choice A rationale
Explaining that anorexia is a natural part of the dying process validates the physiological reality that the body no longer requires fuel. Discussing aspiration risk helps the wife understand that forced feeding could cause harm or discomfort.
Choice B rationale
Nutritional consults and preferred foods are ineffective when a client is actively dying. The focus shifts from nutritional maintenance to comfort. Interventions aimed at increasing caloric intake do not prolong life or improve quality at this terminal stage.
Choice C rationale
While keeping foods available seems supportive, it can create pressure on the client and frustration for the family. In the final stages of life, many clients lack the physical strength or reflex capability to safely consume bedside snacks.
Choice D rationale
Encouraging the wife to feed the client as much as possible increases the risk of choking and aspiration. It places an undue burden on the caregiver and may cause the client physical distress, as their digestive system slows.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Postoperative care focuses on mitigating risks associated with anesthesia and immobility. This question addresses the prevention of atelectasis and pneumonia by applying knowledge of respiratory mechanics, alveolar expansion, and nursing interventions designed to optimize lung volumes and gas exchange.
Choice A rationale
Incentive spirometry promotes deep breathing and lung expansion, preventing alveolar collapse or atelectasis common after surgery. It encourages sustained maximal inspiration, which increases surfactant production and improves oxygenation, maintaining a normal oxygen saturation of 95 to 100 percent.
Choice B rationale
Range-of-motion exercises primarily prevent musculoskeletal stiffness and deep vein thrombosis by promoting venous return. While important for overall recovery, they do not directly expand lung tissue or prevent pulmonary secretions from accumulating in the bronchioles.
Choice C rationale
Expectorants assist in thinning mucus but do not address the primary postoperative risk of hypoventilation or lung collapse. Preventive care prioritizes mechanical expansion of the lungs over pharmacological management of secretions unless a cough is present.
Choice D rationale
Suction equipment is a reactive measure used when secretions already obstruct the airway. Preventive care focuses on proactive lung expansion techniques rather than the equipment needed for emergency or symptomatic management of existing pulmonary distress.
Correct Answer is C
Explanation
Postoperative care for intermaxillary fixation involves prioritizing the airway due to mechanical obstruction. Knowledge of airway management and emergency procedures is necessary to prevent life threatening complications associated with vomiting or secretions when the jaws are wired shut.
Choice A rationale
Pain management is important for postoperative recovery and client comfort. However, it is not the highest priority when compared to the immediate life threatening risk of an obstructed airway, which is common in clients with wired jaws.
Choice B rationale
Oral hygiene is necessary to prevent infection and maintain tissue integrity after mandibular surgery. While important for long term healing, it is a secondary concern that follows the immediate stabilization of respiratory function and airway clearance.
Choice C rationale
Intermaxillary fixation involves wiring the jaws together, making it impossible for the client to clear their airway if they vomit. Preventing aspiration is the priority because it can lead to immediate respiratory distress, pneumonia, or death.
Choice D rationale
Adequate nutrition is vital for bone healing and recovery after a fracture. However, nutritional needs are addressed once the client is stable and the airway is secured. Airway patency always takes precedence over metabolic or nutritional support.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.