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 A
Explanation
Choice A rationale:
The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.
Choice B rationale:
The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.
Choice C rationale:
The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.
Choice D rationale:
The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.
Correct Answer is D
Explanation
Choice A rationale:
"Opioid narcotics are restricted for the client because of the risk for addiction.”. This statement is not accurate. Opioid narcotics are not restricted solely due to the risk of addiction. While there is a potential for addiction with opioids, they are still an essential and effective option for managing severe pain, including end-of-life pain. The key is to use them judiciously and monitor for signs of addiction.
Choice B rationale;
"Using opioid narcotics will limit options available for future management of pain.”Using opioids does not limit future pain management options.
Choice C rationale:
"The use of opioid narcotics is restricted to when death is imminent.”. This statement is not accurate either. Opioid narcotics can be used to manage severe pain in various situations, not just when death is imminent. They are not restricted to end-of-life care only.
Choice D rationale:
"The dosage of the opioid narcotic is unlimited.”. The dosage of opioid narcotics can be increased as needed to manage pain effectively. There is no strict limit, and the goal is to provide adequate pain relief.
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