A nurse is caring for a client who is at the end of life and is unresponsive.
Which of the following actions should the nurse take?
Continue to talk to the client as if they are awake.
Limit the client's visitors to one at a time.
Avoid touching the client.
Whisper when talking in the client's room.
The Correct Answer is A
Choice A rationale:
When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.
Choice B rationale:
Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.
Choice C rationale:
Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.
Choice D rationale:
Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
Choice B rationale:
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
Choice D rationale:
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
Choice E rationale:
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
Correct Answer is D
Explanation
Choice A rationale:
Fibromyalgia. Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tender points. It is not an example of acute pain. Acute pain typically has a sudden onset and is of limited duration.
Choice B rationale:
Peripheral neuropathy. Peripheral neuropathy can cause both acute and chronic pain, depending on the underlying cause. However, it is not a classic example of acute pain. Acute pain is usually associated with a specific injury or condition and has a sudden onset.
Choice C rationale:
Rheumatoid arthritis. Rheumatoid arthritis is a chronic autoimmune condition that can cause joint pain and inflammation. While it can have acute flares of pain, it is primarily considered a chronic condition. Acute pain typically results from injuries or conditions with a sudden onset.
Choice D rationale:
Surgical incision. This is the correct answer. A surgical incision represents a classic example of acute pain. It is a pain that results from a specific event, in this case, surgery, and typically has a well-defined onset and duration. Acute pain is often sharp and intense, and it resolves as the incision heals.
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