A nurse is caring for a terminally ill client on hospice who passed away during the shift. Select the "3" postmortem care actions the nurse should take?

Lay the client's head flat.

Consider any cultural, religious, or social practices of the client that would impact postmortem care.

Dim the lights and minimize noise to provide a calm environment.

Verify the provider has certified and documented death of the client.

Tell the family to leave the room while you prepare the body.

Answer and Explanation

Correct Answer : B,C,D

A. Lay the client's head flat. Keeping the client’s head slightly elevated, rather than flat, helps prevent discoloration from blood pooling in the face. Positioning the body appropriately is part of postmortem care, but laying the head completely flat is not recommended.
B. Consider any cultural, religious, or social practices of the client that would impact postmortem care. Respecting cultural and religious practices is essential in providing compassionate end-of-life care. Some cultures have specific rituals or beliefs regarding handling the body, and the nurse should accommodate these whenever possible.
C. Dim the lights and minimize noise to provide a calm environment. Creating a peaceful environment is important for both the family and staff. A calm, quiet setting allows the family to grieve and say their final goodbyes in a respectful and dignified manner.
D. Verify the provider has certified and documented death of the client. Before proceeding with postmortem care, the nurse must ensure the provider has officially confirmed and documented the time of death. This is a legal requirement and a crucial step in the process.
E. Tell the family to leave the room while you prepare the body. Forcing the family to leave is inappropriate and insensitive. Many families want to be present during postmortem care or take part in rituals. The nurse should offer them the option to stay or leave based on their preference.

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Correct Answer is C

Explanation

A. Visual observation for nonverbal signs of pain. While nonverbal cues such as facial grimacing, restlessness, or guarding can suggest pain, they are subjective and vary between individuals. Some clients may not exhibit obvious signs of pain despite experiencing significant discomfort.
B. The nature and invasiveness of the surgical procedure. Although the type of surgery can provide insight into expected pain levels, pain perception is highly individual. Two clients undergoing the same procedure may report vastly different pain experiences.
C. The client's self-report of pain severity. Self-report is the most reliable indicator of pain intensity. Pain is a subjective experience, and only the client can accurately describe the severity, location, and nature of their discomfort. Pain management should be based primarily on the client’s report.
D. Vital sign measurement. While pain can cause elevated heart rate, blood pressure, or respiratory rate, these signs are not always reliable indicators of pain severity. Some clients may have significant pain with normal vital signs, making self-report the preferred method of assessment.

A. Genetics B. Language barriers C. Poverty D. Transportation access

Correct Answer is C

Explanation

A. Genetics. While genetics play a role in individual health risks, they are not classified as a social determinant of health. Social determinants refer to external factors such as socioeconomic status, education, and environment that influence health outcomes.
B. Language barriers. Limited English proficiency can hinder access to healthcare services, leading to delayed treatment and poor health outcomes. However, language barriers alone do not have as broad or severe an impact as poverty, which affects multiple aspects of health, including nutrition, housing, and access to medical care.
C. Poverty. Poverty is one of the most significant social determinants of health, as it limits access to essential resources such as healthcare, nutritious food, safe housing, and education. Individuals in poverty are at higher risk for chronic diseases, poor mental health, and reduced life expectancy due to financial constraints and systemic inequities.
D. Transportation access. Limited transportation can create barriers to healthcare access, employment, and essential services. While transportation difficulties can contribute to negative health outcomes, they do not have as extensive an impact as poverty, which affects nearly every aspect of a person’s well-being.

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A nurse is caring for a terminally ill client on hospice who passed away during the shift. Select the "3" postmortem care actions the nurse should take?

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