A nurse enters a hospice patient’s room to perform an assessment after receiving the morning report.

The outgoing nurse reports that the patient is showing loss of appetite, swelling of the limbs, increased sleep, CheyneStokes respirations, and hallucinations.

Which of the following indicates the nurse understands the report?

Begin life-saving measures, such as a rapid response call.

Call the provider as these signs and symptoms are abnormal.

Rapid respirations that are unusually deep and regular, and are curative for the patient.

The nurse understands that these are impending signs of death and are normal

The nurse understands that these are impending signs of death and are normal.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

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Correct Answer is D

Explanation

Choice A rationale
Fairness refers to treating all people equally and making decisions without favoritism or prejudice. This is not the most fitting answer because the scenario does not provide information about the nurse treating all patients equally.
Choice B rationale
Confidence in nursing involves trust in one’s abilities and clinical judgment. Although confidence is important in all nursing actions, this scenario does not specifically highlight the nurse’s confidence.

Choice C rationale
Advocacy in nursing refers to the nurse’s role in standing up for the rights and needs of their patient. While notifying the provider could be seen as a form of advocacy, the nurse’s actions in this scenario are more closely aligned with accountability.
Choice D rationale
Accountability in nursing refers to the responsibility of nurses to execute their duties according to standards, being answerable for their actions. In this scenario, the nurse demonstrates accountability by acknowledging the medication error, assessing the patient for any adverse effects, and reporting the incident.

A. Slow capillary refill B. Ringing in the ears C. Cold hands and feet D. Mottled and blotchy skin, especially on the hands, feet, and knees

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

Explanation

Choice A rationale
Slow capillary refill is a sign that the body is not circulating blood as effectively as it should be. This can be a sign that a person is actively dying.
Choice B rationale
Ringing in the ears, also known as tinnitus, is not typically a sign that a person is actively dying. It can be caused by a variety of factors, including exposure to loud noise, certain medications, and some health conditions.
Choice C rationale
Cold hands and feet can be a sign that a person is actively dying. As the body’s systems start to shut down, blood flow to the extremities can decrease, causing them to feel cold.
Choice D rationale
Mottled and blotchy skin, especially on the hands, feet, and knees, can be a sign that a person is actively dying. This is caused by reduced blood flow to the skin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse administers the wrong medication to a patient. After assessing the patient, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?

Correct Answer is D

Explanation

Select physical signs you may see in a patient who is actively dying.

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

Explanation

A nurse is caring for a patient who reports stress related to homelessness. The nurse should identify that the patient is experiencing which of the following types of stressors?

A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

A nurse is assessing an older adult patient who is experiencing age-related changes. Which of the following findings should the nurse expect?

a nurse is caring for a patient who states, “I did not take my medication because my partner forgot to remind me.”. The nurse should identify that the patient is demonstrating which of the following defense mechanisms?

In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

A nurse is caring for a patient who has impaired speech. Which of the following actions should the nurse take?

A nurse is teaching a class about physiological changes to hearing in older adult patients. Which of the following should the nurse include?

A nurse is teaching a class about the stages of the general adaptive syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs during GAS?