A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?
Moist mucous membranes
Tachycardia
Irregular respirations
Hypertension
The Correct Answer is C
Explanation:
A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.
B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.
C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.
D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A. Nonmaleficence: This ethical principle emphasizes the duty of healthcare professionals to avoid causing harm to patients. It involves refraining from actions that could potentially harm the patient, whether physical, emotional, psychological, or social. Nonmaleficence is about acting in a way that promotes the well-being and safety of patients and avoiding actions that could result in harm or injury.
B. Fidelity: Fidelity pertains to the faithfulness, loyalty, and honoring of commitments and promises made to patients. It involves maintaining trust and being truthful in interactions with patients.
C. Beneficence: Beneficence involves the obligation to do good and promote the well-being of patients. It includes actions aimed at benefiting patients, such as providing effective treatments, interventions, and support to improve their health outcomes and quality of life.
D. Justice: Justice relates to fairness and equality in healthcare. It involves the fair distribution of resources, allocation of care, and treatment decisions without discrimination or bias, ensuring that all patients receive equitable care based on their needs and circumstances.
Correct Answer is C
Explanation
Explanation:
A. Increased bowel sounds:
In end-of-life care, clients often experience a decrease in bowel sounds rather than an increase. Bowel sounds may diminish or become absent as the body's systems slow down.
B. Hypertension:
Hypertension is less commonly observed in clients at the end of life. Instead, blood pressure may decrease as the body's overall function declines.
C. Mottled skin:
Mottled skin, characterized by a blotchy or marbled appearance, is a common finding in clients approaching the end of life. It occurs due to changes in peripheral circulation and may indicate decreased perfusion.
D. Moist mucous membranes:
In contrast to moist mucous membranes, clients at the end of life may experience dry mucous membranes. Reduced oral intake and hydration levels can lead to dryness of the mouth and mucous membranes.
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