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: Expressive aphasia impairs speech production due to brain injury, but patients can often use nonverbal methods like gestures or facial expressions. Including a goal for nonverbal communication is realistic, promoting effective interaction while speech therapy progresses. This aligns with the patient’s current abilities and supports functional communication.

Choice B reason: Recovering full speech vocabulary in one day is unrealistic for expressive aphasia, which requires prolonged speech therapy due to neurological damage. This goal sets false expectations, ignoring the chronic nature of traumatic brain injury recovery, and is not appropriate for the care plan.

Choice C reason: Carrying a pen and pad may help some patients, but expressive aphasia does not guarantee writing ability, as written language can also be impaired. This goal is less broadly applicable than nonverbal communication, which leverages intact motor and emotional expression, making it a less suitable choice.

Choice D reason: Thickening drinks prevents aspiration in dysphagia, not aphasia. Expressive aphasia affects speech, not swallowing. This goal is irrelevant to the patient’s condition, as there is no indication of swallowing difficulty, making it an incorrect focus for the care plan.

A. Naps shorter than 20 minutes. B. Takes antidepressant medications. C. Chews gum regularly. D. Sleeps in a hot, stuffy room.

Correct Answer is D

Explanation

Choice A reason: Short naps (15-20 minutes) are recommended for narcolepsy to manage excessive daytime sleepiness without disrupting nighttime sleep. This aligns with evidence-based management, improving alertness. No intervention is needed, as this practice supports symptom control, enhancing daily function and reducing sleep attacks in narcolepsy patients.

Choice B reason: Taking antidepressants, like SSRIs or SNRIs, is standard for narcolepsy to manage cataplexy or sleep disturbances. This is appropriate and requires no intervention unless misuse occurs. The nurse would ensure proper dosing, as antidepressants support symptom control, improving quality of life without disrupting narcolepsy management strategies.

Choice C reason: Chewing gum regularly is benign and unrelated to narcolepsy management. It may help with alertness but doesn’t warrant intervention. Unlike environmental factors like room temperature, gum has no significant impact on sleep quality or narcolepsy symptoms, making it an irrelevant focus for nursing education or correction.

Choice D reason: Sleeping in a hot, stuffy room disrupts sleep quality, exacerbating narcolepsy symptoms like fragmented sleep or daytime sleepiness. The nurse intervenes to promote a cool, well-ventilated sleep environment, critical for optimizing rest. Poor sleep hygiene worsens narcolepsy, reducing treatment efficacy and increasing risks of sleep attacks or fatigue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?

Correct Answer is A

Explanation

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene?

Correct Answer is D

Explanation

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