A nurse is developing a care plan for Mrs. Thompson who is in the end-of-life stage. After assessing the client, the nurse has identified several potential problems. Which of the following hypotheses should the nurse prioritize when planning care for this client?
The client may benefit from additional laboratory tests to monitor disease progression.
The client may experience pain and discomfort due to the progression of their illness.
The client may need increased physical therapy sessions to maintain mobility.
The client may have elevated blood pressure due to an acute exacerbation of their condition.
The Correct Answer is B
A. Additional laboratory tests: While monitoring is essential, at this stage, the priority is comfort, not disease progression.
B. Pain and discomfort: Mrs. Thompson is nearing the end of life and likely experiencing pain due to her advanced metastatic cancer. Pain management should always be a priority in palliative care.
C. Physical therapy: Physical therapy is not typically a priority in the end-of-life stage where the focus is on comfort rather than mobility.
D. Elevated blood pressure: This is unlikely to be the primary concern at this stage. Blood pressure is usually low, and interventions should be focused on comfort and symptom relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Level of sedation. Assessing sedation is the priority because excessive sedation could indicate opioid toxicity, which may precede respiratory depression.
B. Pain level. While assessing pain is essential, it is not the priority when evaluating the safety of opioid administration.
C. Pulse oximetry. Monitoring oxygenation is critical but follows the assessment of sedation, which directly relates to the risk of respiratory depression.
D. Blood pressure. Blood pressure monitoring is important but not as immediate a concern as sedation and respiratory function.
Correct Answer is C
Explanation
A. Spirituality can increase depression: Spirituality often alleviates, rather than increases, depression.
B. Spirituality can increase feelings of hopelessness: Spirituality typically fosters hope and comfort.
C. Spirituality can increase emotional and psychological comfort. Spirituality often helps individuals find meaning, peace, and connection during end-of-life care, improving emotional and psychological well-being.
D. Spirituality can increase the desire to hasten death: Spirituality generally supports coping and a peaceful end-of-life experience rather than a desire to hasten death.
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