A hospice nurse is visiting with the son of a client who has terminal cancer.
The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?

"It is always difficult caring for someone who is terminally ill."

"I can give you information about respite care if you are interested."

"You should consider taking a sleeping pill before bed each night."

"I am sure you're doing a great job taking care of your mother." .

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Acknowledging the difficulty of caring for a terminally ill person is empathetic, but it doesn't offer a solution to the son's problem. The nurse should provide practical assistance or information to help alleviate the son's stress and fatigue.

Choice B rationale:

(Correct Choice) Offering information about respite care is appropriate in this situation. Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Providing information about available resources can empower the son to make decisions that support his well-being and the well-being of his mother.

Choice C rationale:

Suggesting a sleeping pill before bed might not be appropriate without a healthcare provider's assessment. Additionally, relying on medication alone might not address the underlying stress and fatigue the son is experiencing.

Choice D rationale:

Praising the son for his caregiving efforts is supportive, but it doesn't offer a solution to his lack of sleep. While encouragement and recognition are important, addressing the son's immediate need for rest and support should be the priority.

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Correct Answer is A

Explanation

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).

A. Uneven shoulder and pelvic heights. B. Exaggerated curvature of the sacrum. C. Limited range-of-motion of the hips. D. Mild pain in the hip region.

Correct Answer is A

Explanation

Choice A rationale:

"Uneven shoulder and pelvic heights." This is the correct answer. Uneven shoulder and pelvic heights, along with an asymmetrical appearance of the spine when viewed from the back, are clinical manifestations of scoliosis. Scoliosis is a sideways curvature of the spine that often develops during the growth spurt before puberty. Screening for scoliosis typically involves assessing the alignment of the spine and looking for these asymmetries.

Choice B rationale:

Exaggerated curvature of the sacrum is not a typical sign of scoliosis. Scoliosis primarily affects the upper back and can cause a side-to-side curvature of the spine, not the sacrum.

Choice C rationale:

Limited range-of-motion of the hips is not a specific indicator of scoliosis. Restricted hip movement might suggest other musculoskeletal issues but is not directly related to scoliosis.

Choice D rationale:

Mild pain in the hip region is not a characteristic symptom of scoliosis. While scoliosis can cause discomfort, it typically manifests as back pain, not specifically in the hip region. Pain symptoms can vary widely among individuals and might not be present in all cases of scoliosis.

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A hospice nurse is visiting with the son of a client who has terminal cancer.The son reports sleeping very little during the past week due to caring for his mother.Which of the following responses should the nurse make?

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A hospice nurse is visiting with the son of a client who has terminal cancer.
The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?