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 C
Explanation
Choice A rationale
Restlessness is an observable behavior, making it an objective finding.
Choice B rationale
Pacing is also an observable behavior, so it is considered an objective finding.
Choice C rationale
Anxiety is a subjective finding because it is based on the patient’s personal experience and cannot be directly observed.
Choice D rationale
Alertness is an objective finding because it can be directly observed and measured.
Correct Answer is A
Explanation
Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.
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