The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

Keep mucous membranes moist.

Record the client's daily weight.

Maintain in high Fowler's position.

Report any change in urine color.

Answer and Explanation

The Correct Answer is A

A. Keeping the mucous membranes moist is essential for comfort and preventing discomfort associated with dryness, especially in a client who is weak and mouth breathing. This intervention can help prevent issues such as dry mouth, cracked lips, and irritation of the oral mucosa, which can contribute to discomfort and difficulty swallowing.
B.   Monitoring the client's weight can provide valuable information about fluid balance and nutritional status but in the context of a terminally ill client who is weak and refusing to eat or drink, daily weight monitoring may not be as relevant or informative.
C.   The high Fowler's position is often used to improve breathing comfort and lung expansion in clients experiencing respiratory distress. However, in a terminally ill client who is weak and mouth breathing, maintaining them in a high Fowler's position may not be necessary or comfortable.

D.   While monitoring urine output and characteristics is important for assessing renal function and hydration status, changes in urine color may not be a priority in the care of a terminally ill client who is weak and not consuming fluids.

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Correct Answer is A

Explanation

A. Encouraging the client to visualize positive external places, such as peaceful landscapes, serene beaches, or tranquil gardens, can help distract from the pain and promote relaxation. This focus can help shift the client's attention away from the pain sensation, potentially reducing its intensity and improving overall comfort.
B. Tranquil sounds can be utilized but are not a form of guided imagery.

C. Emotional reflection (choice C) may not directly contribute to pain relief during guided imagery sessions.
D. Incorporating motivational phrases during guided imagery can help boost the client's mood, enhance self-confidence, and foster a positive mindset, which may contribute to pain relief and overall well- being. However, positive external places should be the primary focus.

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Encourage the use of incontinence briefs.

Correct Answer is B

Explanation

B. Assisting the client to a bedside commode after meals can help take advantage of the gastrocolic reflex, which typically stimulates bowel movements after eating. This timing may increase the likelihood of successful bowel evacuation and decrease the risk of soiling the bed and clothing.
A. Rectal tubes are sometimes used for bowel management in individuals with chronic fecal incontinence, but they are typically reserved for specific situations and are not commonly used as part of a routine bowel training regimen.
C. Glycerin suppositories are sometimes used to stimulate bowel movements in individuals with constipation, but they are not typically recommended as a routine intervention for managing fecal incontinence.
D. Incontinence briefs can help contain fecal soiling and minimize embarrassment associated with accidents but they do not address the underlying issues contributing to fecal incontinence.

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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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