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.
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Related Questions
Correct Answer is D
Explanation
Explanation:
A. Spirituality can increase feelings of hopelessness.
This statement is generally incorrect. Spirituality often provides individuals with a sense of purpose, meaning, and hope, especially during challenging times such as facing the end of life. It can offer comfort, guidance, and a sense of connection to something greater than oneself, which can alleviate feelings of hopelessness.
B. Spirituality can increase the desire to hasten death.
This statement is not typically true. For many individuals, spirituality provides a source of strength, resilience, and peace, which can help them cope with the end-of-life process without necessarily increasing the desire to hasten death. Spirituality often encourages acceptance, inner peace, and a focus on finding meaning in life's experiences, including the end of life.
C. Spirituality can increase depression.
While spirituality can be a source of support and coping for individuals near the end of life, it is not accurate to say that it increases depression. In fact, spirituality can often provide comfort, solace, and a sense of connection that may help reduce feelings of depression and promote emotional well-being.
D. Spirituality can increase the quality of life.
This statement is correct. Many studies and anecdotal evidence suggest that spirituality plays a significant role in enhancing the quality of life for individuals facing the end of life. It can provide comfort, peace, meaning, and a sense of connection with others, one's beliefs, and the universe, contributing to overall well-being and quality of life.
Correct Answer is ["C","D","E"]
Explanation
Explanation:
A. Bathtub with rails:
Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.
B. Raised toilet seats:
Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.
C. Electric cords behind furniture:
Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.
D. Water heater temperature 54.4°C (130° F):
The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.
E. Throw rugs:
Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.
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