The nurse is assessing a terminally ill client who is on home hospice care and notes that the client is demonstrating signs of terminal delirium and becoming more unresponsive. Which of the following instructions should the nurse give to the client’s children?
"We recommend that you sit at your parent's bedside so you can document the time of death."
"Limit the amount of environmental noise in your parent's room to decrease stimulation."
"This may be very difficult for you to watch your parent, so take some respite time to re-charge."
"Family often uses this time to tell their parent that it is okay to let go."
The Correct Answer is B
A. Documenting the time of death is not an immediate concern during the process of terminal delirium and does not directly address the patient's comfort.
B. Limiting environmental noise helps reduce stimulation, which can be beneficial for a patient experiencing terminal delirium and unresponsiveness, helping to maintain a calm environment.
C. While taking respite time may be necessary for family members, it does not directly address the needs of the patient with terminal delirium.
D. Telling the patient it is okay to let go is emotionally supportive but does not address the immediate need to manage symptoms and provide comfort during terminal delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing medications for pain and discomfort helps manage symptoms but does not directly address skin integrity.
B. Using an air mattress is effective in reducing pressure on bony prominences, thereby preventing pressure ulcers and promoting skin integrity.
C. Applying lotion helps with skin hydration but does not address the pressure that can lead to skin breakdown.
D. Educating family members about turning and repositioning is important but does not provide the physical support needed to reduce pressure on the skin as effectively as an air mattress.
Correct Answer is D
Explanation
A. Evaluating self-administration of insulin involves assessing a client's ability to manage their medication, which requires skilled nursing assessment and education.
B. Auscultating lung sounds is a skilled nursing task involving clinical assessment of respiratory status.
C. Monitoring blood pressure is a skilled nursing task that requires clinical assessment, especially when adjusting medications.
D. Changing a dry dressing is considered non-skilled care as it primarily involves routine care and does not require advanced clinical skills. This task is appropriate for a non-skilled caregiver.
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