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 ["7"]
Explanation
Step 1 is 350 mg ÷ 250 mg × 5 mL.
Step 2 is 1.4 × 5 mL.
Step 3 is 7 mL.
Correct Answer is ["B","D","E","F"]
Explanation
The clinical scenarios involve oncological emergencies, acute neurological deficits, hepatic coagulopathy, and end of life ethics. Knowledge of vascular obstruction, cerebral perfusion, liver physiology, and therapeutic communication is required to identify life threatening complications and uphold patient autonomy in advanced illness.
Choice A rationale
Abdominal pain is not a primary manifestation of superior vena cava syndrome. This condition involves obstruction of blood flow through the superior vena cava, primarily affecting the upper body, head, and neck rather than the abdominal cavity or viscera.
Choice B rationale
Dyspnea occurs as the tumor or thrombus compresses the superior vena cava, leading to impaired venous return and pulmonary congestion. This increased venous pressure in the upper thoracic region compromises respiratory efficiency and necessitates urgent medical intervention for stabilization.
Choice C rationale
Decreased urine output is typically associated with renal failure or systemic hypovolemia rather than localized superior vena cava obstruction. While cardiac output might eventually drop, oliguria is not a classic diagnostic symptom used to confirm this specific oncological emergency.
Choice D rationale
Obstruction of the superior vena cava causes a significant increase in venous pressure above the heart. This backup of blood leads to visible engorgement of the jugular veins as the blood cannot return efficiently to the right atrium.
Choice E rationale
Edema in the upper extremities and face results from increased capillary hydrostatic pressure due to venous return blockage. Fluid shifts into the interstitial spaces of the head, neck, and arms, causing the characteristic swelling and puffiness seen.
Choice F rationale
Chest pain and shortness of breath arise from increased intrathoracic pressure and decreased cardiac preload. The physical mass causing the syndrome often occupies the mediastinal space, leading to localized discomfort and significant respiratory distress during the acute phase.
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