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. Maturational loss B. Situational loss C. Perceived loss D. Uncomplicated loss

Correct Answer is B

Explanation

Choice A reason: Maturational loss occurs with normal developmental transitions, like aging or menopause. Amputation from military injuries is an unexpected event, not a developmental milestone. This type does not apply to the veteran’s sudden, trauma-related loss, making it incorrect for the care plan focus.

Choice B reason: Situational loss results from unpredictable events, like amputation due to military injuries. This loss impacts the veteran’s mobility, identity, and lifestyle, requiring targeted interventions for grief, adaptation, and rehabilitation. The nurse’s care plan should focus on addressing this situational loss to support emotional and physical recovery.

Choice C reason: Perceived loss is subjective, like loss of self-esteem, but amputation is a tangible, objective loss of limbs. While emotional impacts exist, the primary loss is physical and situational. This type is less specific to the veteran’s experience, making it an incorrect focus for the care plan.

Choice D reason: Uncomplicated loss refers to normal grief without complications, not a specific type of loss. Amputation is a complex situational loss with physical and psychological impacts. This term does not capture the nature of the veteran’s experience, making it inappropriate for the care plan focus.

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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

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

Correct Answer is B

Explanation

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