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. Spirituality decreases feelings of depression:
This statement is generally accurate. Many studies and anecdotal evidence suggest that spirituality can have a positive impact on mental and emotional well-being, including reducing feelings of depression and providing a sense of peace and comfort.
B. Spirituality increases feelings of hopelessness:
This statement is not typically supported by research or clinical observations. Spirituality often fosters feelings of hope, meaning, and purpose, which can counteract feelings of hopelessness commonly experienced by individuals facing end-of-life challenges.
C. Spirituality increases the desire to hasten death:
There is limited evidence to support this statement. In fact, spirituality often provides individuals with a sense of resilience, acceptance, and coping mechanisms that may reduce the desire to hasten death. However, individual beliefs and experiences can vary widely.
D. Spirituality decreases quality of life:
This statement is generally inaccurate. For many individuals, spirituality enhances quality of life by providing a sense of meaning, connection, and comfort, especially during challenging times such as end-of-life care.
Correct Answer is ["B","C","D","E"]
Explanation
A. Grab bars are installed in the bathroom:
Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.
B. Medications are stored in a clear bag:
Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.
C. Area rugs are placed in the living room:
Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.
D. Dim lighting installed throughout the house:
Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.
E. The hot water heater is set at 54°C (130° F):
Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.
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