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)
Mottling of the skin in the lower extremities
Increased blood pressure
Cheyne-Stokes breathing
Warm, dry, and pink skin
Regular respiration
Correct Answer : A,C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Skeletal muscles do not enable the heart to contract with each heartbeat. The heart has its own specialized muscle tissue known as cardiac muscle, which allows it to contract and pump blood throughout the body.
Choice B rationale
Skeletal muscles do not enable the bladder to contract during voiding. The detrusor muscle, a smooth muscle found in the wall of the bladder, contracts during urination to expel urine from the body.
Choice C rationale
Skeletal muscles do not enable the bronchioles to dilate in the lungs. The dilation and constriction of the bronchioles are controlled by the autonomic nervous system and the smooth muscles in the walls of the bronchioles.
Choice D rationale
Skeletal muscles do enable a hand to contract and form a fist. Skeletal muscles are responsible for all voluntary movements, including making a fist. When you want to make a fist, your brain sends a signal to the skeletal muscles in your hand and forearm, telling them to contract. This pulls on the tendons connected to your fingers, causing them to move and form a fist.
Correct Answer is B
Explanation
Choice A rationale
While it’s important for the client to understand the alternatives to the procedure, it’s typically the responsibility of the physician or surgeon to explain these alternatives, not the nurse.
Choice B rationale
One of the nurse’s responsibilities in the informed consent process is to confirm that the client is competent to sign for the procedure. This means ensuring that the client understands the procedure, its risks and benefits, and is making the decision voluntarily.
Choice C rationale
Discussing the risks of the procedure with the client is typically the responsibility of the physician or surgeon, not the nurse.
Choice D rationale
While the nurse may provide some information about what will occur during the procedure, it’s typically the responsibility of the physician or surgeon to provide detailed information about the procedure.
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