A nurse is caring for a child who is dying. Which of the following are findings of impending death? (Select all that apply.)
Sensation of being cold
Heightened sense of hearing
Difficulty swallowing
Tachycardia
Cheyne-Stokes respirations
Correct Answer : A,C,D,E
Choice A reason: A sensation of being cold can occur as the body's circulation diminishes and blood flow to the extremities decreases.
Choice B reason: A heightened sense of hearing is not typically a sign of impending death; this choice is incorrect.
Choice C reason: Difficulty swallowing can be a sign of impending death due to the body's muscles weakening and a decrease in reflexes.
Choice D reason: Tachycardia may occur as the heart tries to compensate for decreased function in other systems.
Choice E reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing, are a common sign of impending death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Bowel sounds are a general indicator of intestinal activity and can be assessed in patients with various conditions. However, they are not specific to the effectiveness of Esomeprazole, which is primarily used to reduce gastric acid production and prevent stress ulcers, particularly in patients with burn injuries⁷.
Choice B reason:
Stool frequency may indicate gastrointestinal motility and function but does not directly assess the effectiveness of Esomeprazole. This drug's main role is to decrease stomach acidity, which would not necessarily change stool frequency unless there was a pre-existing issue related to acid production⁷.
Choice C reason:
Abdominal distention can be caused by a variety of factors, including gas, fluid, or enlargement of organs. While it's important to monitor in burn patients, it does not specifically evaluate the effectiveness of Esomeprazole in preventing gastric acid-related complications⁷.
Choice D reason:
A fecal occult blood test is used to detect bleeding in the gastrointestinal tract, which could signify the development of stress ulcers. Since Esomeprazole is prescribed to prevent such ulcers by reducing stomach acid, this test is a direct measure of the drug's effectiveness in burn patients⁷.
Correct Answer is C
Explanation
Choice A reason: Medication should not be cool as it can cause discomfort or even reflexive actions like vomiting or vertigo. It should be at room temperature⁷.
Choice B reason: Hyperextending the infant's neck is not necessary and could be uncomfortable or unsafe. The position should be natural and comfortable⁷.
Choice C reason: Pulling the pinna downward and straight back is the correct method for infants to straighten the ear canal for proper administration of otic medication⁷.
Choice D reason: Holding the infant in an upright position is not ideal for otic medication administration. The infant should be lying down or sitting with the affected ear facing up⁷.
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