A hospice nurse is planning care for a patient who is near death.
Which of the following actions should the nurse include in the patient’s plan of care to promote the patient’s comfort?

Turn the patient every 4 hours.

Elevate the head of the patient’s bed.

Offer the patient ice chips.

Provide oral care to the patient every 6 hours.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B

Choice A rationale: Turning the patient every 4 hours may prevent pressure ulcers, but it can cause discomfort for a near-death patient. Less frequent repositioning might be more suitable for maintaining comfort during the end-of-life stage.

Choice B rationale: Elevating the head of the patient's bed can help ease breathing difficulties by reducing the pressure on the diaphragm and enhancing lung expansion. This position promotes comfort and reduces the work of breathing, which is beneficial for near-death patients.

Choice C rationale: Offering the patient ice chips can provide temporary relief from dry mouth, but it may not be the most effective measure for ensuring comfort. Adequate hydration and regular oral care are generally more beneficial for maintaining patient comfort.

Choice D rationale: Providing oral care every 6 hours might not be frequent enough to ensure comfort. More frequent oral care, such as every 2 hours, helps maintain moisture in the mouth, reduces discomfort, and prevents infections, enhancing the patient's overall comfort

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Correct Answer is B

Explanation

Choice A rationale

Asking the client to describe how they are feeling today is an important part of the assessment. However, when dealing with a client who is managing depression, the nurse’s first priority should be to ensure the safety of the client.

Choice B rationale

Asking if the client is having any thoughts about hurting themselves is the first question the nurse should ask. This is because safety is always the top priority, and clients dealing with depression may be at risk for self-harm or suicide.

Choice C rationale

While it’s important to understand what makes the client feel less depressed, this question is not as immediately critical as assessing for potential self-harm or suicide risk.

Choice D rationale

Understanding the client’s support system is an important part of the assessment, but it is not the first priority. The nurse’s initial focus should be on assessing the client’s immediate safety and mental health status.

A. Direct conversation to the parents to avoid embarrassing the adolescent. B. Determine how the adolescent’s health has affected family roles. C. Focus the discussion on the adolescent’s future career plans. D. Ask another family from the same faith congregation to attend the meeting for support.

Correct Answer is B

Explanation

Choice A rationale

While it’s important to respect the adolescent’s privacy and avoid causing embarrassment, directing the conversation solely to the parents may not fully address the needs of the adolescent. Adolescents with cancer often have their own questions and concerns, and they should be included in discussions about their care.

Choice B rationale

This is the correct answer. Understanding how the adolescent’s health has affected family roles can help the nurse provide appropriate support and resources. Cancer can significantly impact family dynamics, and addressing these changes is an important part of holistic care.

Choice C rationale

While discussing future career plans can be a part of the conversation, it should not be the primary focus of the meeting. The immediate concern is usually the adolescent’s health and well-being.

Choice D rationale

While support from the faith community can be beneficial, it’s important to respect the family’s privacy. Inviting another family from the same faith congregation to attend the meeting should only be done with the family’s consent.

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A hospice nurse is planning care for a patient who is near death. Which of the following actions should the nurse include in the patient’s plan of care to promote the patient’s comfort?

Nursing Test Bank

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A hospice nurse is planning care for a patient who is near death.
Which of the following actions should the nurse include in the patient’s plan of care to promote the patient’s comfort?