Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

The primary survey in trauma management focuses on life threatening conditions using the airway, breathing, circulation, disability, and exposure sequence. Knowledge of emergency stabilization techniques is required to prioritize rapid assessment and immediate interventions for physiological survival during the initial encounter.

Choice A rationale

Cervical spine stabilization prevents permanent spinal cord injury during airway management. In trauma, any mechanism of injury involving high velocity or impact requires strict spinal precautions until the spine is radiographically cleared or physically assessed for stability.

Choice B rationale

Obtaining a comprehensive history is part of the secondary survey, specifically the AMPLE assessment. The primary survey focuses only on immediate life threats and physiological stabilization, delaying detailed data collection until the client is determined to be stable.

Choice C rationale

Elevating the head of the bed may compromise spinal alignment before clearance and is not a priority in the ABCDE sequence. Management typically focuses on maintaining a flat, supine position on a backboard to protect the spine.

Choice D rationale

The Glasgow Coma Scale assessment is a core component of the disability portion of the primary survey. It provides a standardized method to evaluate neurological status, including eye opening, verbal response, and motor response to stimuli.

Choice E rationale

Prevention of hypothermia is the exposure and environment stage of the primary survey. Maintaining normothermia is vital because hypothermia can lead to coagulopathy and metabolic acidosis, forming a lethal triad that significantly increases trauma mortality..

A. It reduces the client's blood pressure. B. It decreases the client's level of anxiety. C. It facilitates the client's deep breathing. D. It enhances the client's ability to sleep.

Correct Answer is C

Explanation

Postoperative care for cardiac surgery requires balancing pain management with respiratory function. Knowledge of pulmonary mechanics and the risks of atelectasis is necessary to identify how analgesia facilitates deep breathing and coughing to prevent pneumonia and improve oxygenation.

Choice A rationale

Opioids can cause vasodilation and subsequent hypotension, but reducing blood pressure is not the therapeutic goal of analgesia in this context. While beneficial for cardiac workload, it is not the most critical recovery factor here.

Choice B rationale

Anxiety reduction is a secondary benefit of pain control that improves patient comfort. However, physiological stabilization and the prevention of respiratory complications take precedence over psychological comfort in the immediate postoperative phase after a bypass.

Choice C rationale

Postoperative pain causes guarded, shallow respirations, increasing the risk of lung collapse. Effective analgesia allows the client to perform deep breathing and incentive spirometry, which are vital for maintaining alveolar expansion and preventing secondary infections.

Choice D rationale

Sleep is necessary for cellular repair and overall recovery. While opioids help a patient rest, the primary physiological priority for a bypass patient is maintaining adequate gas exchange through effective ventilation, which requires active respiratory effort.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency department following a motor vehicle accident. Which nursing actions should the nurse take during the primary survey?

Correct Answer is ["A","D","E"]

Explanation

Correct Answer is C

Explanation

An intubated client with increased intracranial pressure has pooled secretions in the airway. Which action should the nurse take first?

The client is admitted to the emergency department with a full-thickness burn over the front of both legs. Which priority intervention should the nurse implement?

The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer?

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

A client with cirrhosis and severe ascites is scheduled for a paracentesis. Post-procedure, the client develops signs of tachycardia, hypotension, and mild fever. Which conditions could cause these symptoms? Select all that apply.

The nurse plans care for a client with a traumatic brain injury who exhibits signs of post-concussion syndrome, including headaches, irritability, and sleep disturbances. Which strategy should the nurse include in the client's care plan?

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

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?