A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?
Encourage the family to involve siblings when caring for the child.
Reinforce with the family that they should avoid discussing death with the child.
Collect vital signs every 2 hr as the child's condition deteriorates.
Perform passive range of motion to the child's extremities every 4 hr.
The Correct Answer is A
A. Encouraging the family to involve siblings in the care of the terminally ill child is important for fostering family support, allowing siblings to understand the situation, and promoting emotional bonding.
B. Avoiding discussions about death is not recommended. It is important to communicate with the child about death in an age-appropriate manner to help them understand and cope with the situation.
C. While monitoring vital signs is important, it is not the most therapeutic intervention in the final stages of terminal illness. Comfort care, including pain management and emotional support, takes priority.
D. Passive range of motion is not essential for a child in the final stages of terminal illness unless necessary for specific comfort or mobility needs. Care should focus on comfort measures rather than routine interventions.
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Related Questions
Correct Answer is C
Explanation
A. Selecting a catheter that fits snugly is important for proper suctioning, but it is more important to ensure the catheter is the correct size for the infant’s tracheostomy tube and airway.
B. Instilling saline prior to suctioning is generally not recommended unless specified by the healthcare provider, as it can increase the risk of aspiration and discomfort.
C. Suctioning should be done in short 3 to 4 second increments to avoid injury to the airway and to minimize the infant’s distress. Prolonged suctioning can cause hypoxia and trauma to the mucosa.
D. Suctioning for infants with tracheostomies requires sterile technique to prevent infection, not clean technique.
Correct Answer is D
Explanation
A. While it is important to maintain confidentiality, the nurse must follow mandatory reporting laws for suspected abuse, which may require informing appropriate authorities.
B. While it may be important to acknowledge the harm done, directly labeling the parent's behavior as "wrong" could potentially escalate the situation and may not be helpful in building rapport with the adolescent.
C. Making assumptions about the behavior of another parent can be seen as judgmental and may not be helpful in addressing the adolescent’s concerns or in facilitating a safe environment for disclosure.
D. This response provides reassurance to the adolescent that they are not responsible for the abuse and helps to create a nonjudgmental, supportive environment, allowing the adolescent to feel safe and heard.
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