A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death?

Cheyne-Stokes breathing

Redness of skin

Tense muscle tone

Clear colored urine

Answer and Explanation

The Correct Answer is A

Choice A reason: Cheyne-Stokes breathing, alternating cycles of deep breathing and apnea, is a hallmark of impending death, often seen in the final hours. It reflects brainstem dysfunction as the body shuts down. This finding signals the nurse to prepare the family for imminent death, providing emotional support and guidance.

Choice B reason: Redness of skin may indicate pressure injuries or fever but is not a specific sign of imminent death. In the dying process, skin may become mottled or pale, not red. This finding does not prompt immediate preparation for death, making it an incorrect choice.

Choice C reason: Tense muscle tone is not typical in the last stages of dying, where muscles relax due to metabolic shutdown. Rigidity occurs post-mortem (rigor mortis). This finding does not indicate imminent death, so it does not require preparing the family, making it incorrect.

Choice D reason: Clear colored urine reflects hydration but is not a sign of impending death. In the dying process, urine output decreases, and color darkens due to reduced renal perfusion. This finding is irrelevant to preparing the family for death, as it does not signal the final stages.

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Correct Answer is A

Explanation

Choice A reason: The nurse promotes hope by helping the depressed patient identify activities to look forward to, fostering optimism and purpose. Hope, a spiritual concept, counteracts despair, enhancing mental health per psychological resilience models. This intervention supports emotional recovery, critical for patients with severe depression facing existential challenges.

Choice B reason: Time management is a practical skill, not a spiritual concept, and unrelated to identifying positive activities in depression. The nurse’s focus is hope, not organization. Assuming time management misaligns with the intervention, risking neglect of the patient’s spiritual need for meaning, critical for addressing depressive hopelessness and recovery.

Choice C reason: Reminiscence involves recalling past experiences, not future-oriented activities, as the nurse encourages. Hope targets forward-looking optimism, not reflection. Assuming reminiscence misguides the intervention, potentially missing the patient’s need for hope to combat depression, delaying emotional recovery and engagement in meaningful activities for mental health.

Choice D reason: Faith involves religious or spiritual beliefs, not specifically identifying future activities, as the nurse does to foster hope. While faith may support hope, the intervention targets optimism broadly. Assuming faith risks narrowing the focus, potentially overlooking non-religious patients’ need for hope, critical for depression management and emotional resilience.

A. Experiences. B. Illness. C. Values. D. Health.

Correct Answer is A

Explanation

Choice A reason: Intersectionality examines how overlapping identities (e.g., race, gender, socioeconomic status) shape unique experiences of health and care. Focusing on experiences allows nurses to address disparities and tailor interventions, ensuring equitable care. This approach recognizes systemic factors, critical for understanding patients’ barriers and needs in diverse healthcare contexts.

Choice B reason: Focusing on illness alone overlooks intersectionality’s emphasis on how social identities shape health experiences. Illness is a clinical factor, not a social construct like race or class. This narrow focus risks missing systemic inequities, reducing care effectiveness for patients with complex social determinants influencing their health outcomes.

Choice C reason: Values are personal beliefs, not the primary focus of intersectionality, which examines social identities and systemic inequities shaping experiences. Prioritizing values risks ignoring structural factors like discrimination, limiting the nurse’s ability to address disparities and provide culturally sensitive care critical for patients from marginalized backgrounds.

Choice D reason: Health is an outcome, not the focus of intersectionality, which explores how identities like ethnicity or gender create unique experiences of care access and treatment. Focusing on health alone misses social determinants, risking generic care that fails to address inequities, critical for equitable nursing practice in diverse populations.

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A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death?

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Naxlex Comprehensive Predictor Exams

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Explanation

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