A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?
"Call me so that I can help you change your position."
"Try to close your eyes and get some sleep."
"It is common for breathing to become more difficult as time goes on."
"Therapy choices are limited for clients who do not want resuscitation."
The Correct Answer is A
Choice A Reason:
"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.
Choice B Reason:
"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.
Choice C Reason:
"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.
Choice D Reason:
"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I'll listen to my favorite music to take my mind off the pain." This statement refers to distraction techniques, like listening to music, which can help manage pain but isn't specifically guided imagery.
Choice B Reason:
"I'll think about my grandfather's farm to reduce pain." This statement indicates an understanding of this technique. Guided imagery involves creating a detailed mental image or scenario that promotes relaxation and diminishes pain perception. In this case, the client visualizing a familiar, pleasant place like their grandfather's farm can be an effective form of guided imagery to alleviate pain by diverting attention and inducing relaxation.
Choice C Reason:
"I'll use focused breathing to control my pain." This statement does not indicate an understanding of this technique.
Focused breathing, while beneficial for relaxation and pain management, is a different technique from guided imagery.
Choice D Reason:
"I'll learn to notice the sensation of muscle tension." This statement refers to progressive muscle relaxation, a technique involving systematically tensing and relaxing muscle groups, which isn't guided imagery.
Correct Answer is C
Explanation
Choice A Reason:
Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.
Choice B Reason:
Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.
Choice C Reason:
Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.
Choice D Reason:
Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.
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