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 C

Explanation

Choice A reason: A belief tool is not a standardized method for spiritual assessment. The FICA tool specifically evaluates faith, importance, community, and action, including questions about God and purpose. Assuming a vague belief tool risks incomplete assessment, missing critical spiritual needs that influence patient coping and well-being in holistic care settings.

Choice B reason: The spiritual well-being scale measures general spiritual health but is not structured for detailed questions about God or life purpose, unlike the FICA tool’s targeted approach. Using this risks missing specific spiritual concerns, limiting the nurse’s ability to address existential needs critical for patient support in illness or end-of-life care.

Choice C reason: The FICA assessment tool (Faith, Importance, Community, Action) involves structured questions to evaluate spiritual beliefs, including relationships with God and life purpose. Its comprehensive 20-question format assesses spiritual needs, guiding holistic care. This method ensures tailored interventions, supporting emotional and spiritual well-being, critical for patients facing serious health challenges.

Choice D reason: The hope scale measures optimism but not specifically the relationship with God or life purpose, unlike the FICA tool’s broader spiritual focus. Assuming this method risks overlooking religious or existential concerns, reducing the effectiveness of spiritual care in addressing patient needs for meaning and satisfaction during health crises.

A. Delegate complex nursing tasks to nursing assistive personnel. B. Write for 10 minutes in a journal every day. C. Use progressive muscle relaxation. D. Strengthen friendships outside the workplace.

Correct Answer is C

Explanation

Choice A reason: Delegating complex tasks to assistive personnel is inappropriate, as it may compromise patient safety and violate scope of practice. While delegation reduces workload, it does not address emotional or physiological stress directly. This strategy is less effective for burnout prevention compared to relaxation techniques.

Choice B reason: Journaling for 10 minutes daily can help process emotions but is less immediate in reducing physiological stress. Burnout involves physical and emotional exhaustion, and while reflective writing is beneficial, it is not as effective as progressive muscle relaxation in directly alleviating stress-related tension.

Choice C reason: Progressive muscle relaxation reduces burnout by systematically tensing and relaxing muscles, lowering cortisol and promoting calmness. This evidence-based technique directly addresses the physical and emotional toll of a stressful nursing unit, making it the best strategy for a new nurse to prevent burnout effectively.

Choice D reason: Strengthening friendships outside work supports social well-being but does not directly alleviate acute stress or physical exhaustion from extra shifts. While valuable, it is less immediate than progressive muscle relaxation in addressing burnout’s physiological effects, making it a less optimal strategy.

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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

In caring for the patient’s spiritual needs, the nurse asks 20 questions to assess the patient’s relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using?

Correct Answer is C

Explanation

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use?

Correct Answer is C

Explanation

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