A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client’s family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion?
Regular breathing patterns
Warm extremities
Increased urine output
Decreased muscle tone
The Correct Answer is D
Rationale:
A. In the final hours of life, clients rarely maintain regular breathing. Instead, they often experience irregular respirations, including periods of rapid breathing followed by apnea, known as Cheyne-Stokes respirations. These fluctuations result from decreased perfusion to the brain and respiratory centers as the body begins to shut down, making regular breathing an inaccurate expectation.
B. As death approaches, circulation to the periphery diminishes, causing the extremities to become cool, pale, or mottled. Warm extremities are not typical during this stage, and families should be educated that changes in skin temperature and color are normal physiological responses to impending death.
C. Renal function declines as perfusion decreases in the dying process. This results in decreased urine output or oliguria, not an increase. A sudden increase in urine output could indicate an unrelated pathology rather than a normal dying process.
D. One of the expected physiological changes in the final hours of life is decreased muscle tone. This includes relaxation of facial muscles, jaw, eyelids, and extremities, reflecting the body’s progressive loss of voluntary motor control. Educating the family about decreased muscle tone helps them understand that these changes are normal and not a cause for alarm. It also allows the nurse to provide guidance on comfort measures, such as gentle repositioning and maintaining dignity, and supports the family’s emotional coping during the dying process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Step 1: Determine the concentration per mL
250 mg ÷ 5 mL = 50 mg/mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration per mL
Volume = 750 ÷ 50 = 15 mL
Final Answer: 15 mL
Correct Answer is D
Explanation
Rationale:
A. Assault involves threatening or causing a client to fear imminent harm. In this scenario, the nurse did not threaten the client; the action was the actual administration of medication against the client’s will, which goes beyond mere threat.
B. Negligence refers to failure to provide care in a reasonable and safe manner, resulting in harm. While negligence could involve medication errors or omissions, this scenario involves intentional administration despite refusal, which is not negligence but an intentional tort.
C. False imprisonment involves restraining a client’s freedom of movement without consent or legal justification. Administering medication does not directly restrict movement, so false imprisonment is not the correct classification here.
D. Battery is the intentional, unauthorized physical contact or treatment inflicted on a client. By administering the analgesic injection despite the client’s competent refusal, the nurse committed battery, because the client did not consent to the procedure. In healthcare, consent is mandatory for all treatments and interventions; violating this principle constitutes an intentional tort.
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