A hospice client is being cared for by the nurse at home. The client begins to experience changes in respirations, coughing and becoming increasingly restless. Based on these clinical manifestations, the nurse would implement which of the following interventions? (SELECT ALL THAT APPLY) ( Medical orders are active for each intervention that would require a medical order.)

Call for transportation to the hospital

Initiate low-flow oxygen per nasal cannula

Provide relief from pain and from other distressing symptoms

Place the bed in semi-Fowler's position

Administer anti-anxiety medications as needed

Answer and Explanation

Correct Answer : C,D

C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.

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Correct Answer is D

Explanation

D. While considering the opinions of the deceased when making decisions may reflect a continued emotional connection to the deceased partner, it does not necessarily indicate unresolved grief. Many individuals maintain a sense of connection to deceased loved ones and may consider their perspectives or values when making decisions, even after a significant amount of time has passed since the loss. This behavior can be a way of honoring the memory of the deceased and integrating their influence into decision-making processes.
A. Attending grief support group meetings indicates that the client is actively seeking support and processing their grief in a supportive environment. This behavior is consistent with healthy grieving and can contribute to the process of grief resolution by providing opportunities for validation, sharing experiences, and receiving support from others who have experienced similar losses.
B. Being future-oriented and able to discuss the details of everyday life suggests that the client is able to focus on present and future aspects of life, rather than being consumed by grief. This can be a positive sign of adaptation and adjustment to life without the deceased partner. It indicates that the client is able to engage in activities of daily living and plan for the future, which are important aspects of grief resolution.
C. Grief is a complex and individual process that often involves periods of intense emotions, including waves of grief triggered by reminders of the deceased loved one. Experiencing occasional waves of grief triggered by pictures or events is a common experience in the grieving process and does not necessarily indicate unresolved grief. Instead, it reflects the ongoing nature of grief and the client's emotional connection to the deceased.

A. decreased blood glucose B. Increased mental acuity C. Increased urine retention D. increased bronchial dilation E. decreased pupil size

Correct Answer is ["B","C","D"]

Explanation

B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.

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Naxlex Comprehensive Predictor Exams

The nurse recognizes that which behavior would not be considered a sign of grief resolution in a client whose partner died a year ago? The client

Correct Answer is D

Explanation

Which of the following are physiologic manifestations which occur in the alarm stage of the General Adaptation Syndrome? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?

A client is receiving an intravenous (IV) solution over a short amount of time to replace volume losses. The nurse understands that this IV solution is most likely to be:

Two clients have been in a similar motor vehicle accident, and have similar injuries. The nurse observes each client's different responses to this stressor. The nurse understands that the degree of stress each client experiences from the crash may be influenced by their: (SELECT ALL THAT APPLY)

A client with a history of takes about 15 antacid tablets per day. The nurse understands that this client is at risk for:

The nurse is caring for a client who just had a subclavian central venous catheter inserted. Which symptom should the nurse recognize as setting a priority for this client's care?

A drug that is classified as being a "hypnotic" means that it will:

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

The nurse is caring for a client who is discussing being placed on hospice care. Which statement by the client indicates an understanding of hospice care?