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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While palliative care can indeed help improve a patient’s quality of life, it is not typically aimed at curing the disease or significantly prolonging life. Instead, the focus is on managing symptoms and improving comfort. Therefore, the statement “This treatment should help me live a little longer and give me hope for a cure” does not accurately reflect the goals of palliative care.
Choice B rationale
The statement “I will continue my strict dietary plan” does not necessarily indicate an understanding of palliative care. While maintaining good nutrition can be an important part of managing some conditions, palliative care is more focused on symptom management and improving quality of life. Strict dietary restrictions may not be necessary or beneficial in a palliative care context.
Choice C rationale
The statement “I am hoping this will limit my discomfort and give me the best quality of life for me” accurately reflects the goals of palliative care. Palliative care aims to manage symptoms, including pain and discomfort, and to improve the patient’s quality of life.
Choice D rationale
The statement “This is not working and I plan to stop treatment” does not necessarily reflect an understanding of palliative care. While a patient has the right to stop treatment at any time, this decision should be based on a thorough understanding of their condition and the potential benefits and drawbacks of continuing or discontinuing treatment.
Correct Answer is D
Explanation
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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