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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Installing handrails in the bathroom is a recommended strategy for reducing the risk of falls. Handrails provide support and stability, particularly in slippery environments like the bathroom.
Choice B rationale
Using a standard height toilet seat is not necessarily a recommended strategy for reducing the risk of falls. A toilet seat at an appropriate height for the individual would be more beneficial.
Choice C rationale
Wearing backless shoes is not a recommended strategy for reducing the risk of falls. Shoes with good support and non-slip soles are typically recommended.
Choice D rationale
Covering extension cords with a throw rug is not a recommended strategy for reducing the risk of falls. This could potentially create a tripping hazard.

A. Mottling of the skin in the lower extremities B. Increased blood pressure C. Cheyne-Stokes breathing D. Warm, dry, and pink skin E. Regular respiration

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

Explanation

Choice A rationale
Mottling of the skin, especially in the lower extremities, is a common sign of impending death. This is due to decreased blood flow and can be a sign that the body is starting to shut down.
Choice B rationale
This statement is incorrect. As a person nears death, their blood pressure typically decreases, not increases.
Choice C rationale
Cheyne-Stokes breathing, which is characterized by a pattern of increasing and decreasing respiration with periods of apnea, is a common symptom in the final stages of life.
Choice D rationale
This statement is incorrect. As a person nears death, their skin may become cool to the touch and may appear pale or mottled.
Choice E rationale
Regular respiration is not typically a sign of impending death. In fact, changes in breathing patterns, such as Cheyne-Stokes breathing, are more common.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

, a nurse is teaching a patient about reducing the risk for falls. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is assessing a patient who is in the active stage of dying. What are the signs and symptoms of impending death? (Select all that apply)

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

Explanation

A nurse is teaching a group of older adults about risk factors for developing a stroke. Which non-modifiable risk factors should the nurse include in the teaching?

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?

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 reviewing a fall risk assessment for a client. Which of the following findings place the client at risk for a fall? Select all that apply.

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?

a nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A nurse is caring for a patient with moderate vision impairment. What actions should the nurse take?