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 B
Explanation
A. Encourage visitors throughout the day: Increased visitor interactions may worsen sensory overload by adding more stimuli.
B. Provide the client with earplugs. Earplugs help reduce environmental noise and sensory input, addressing the client's sensory overload and promoting rest and comfort.
C. Spread client care activities throughout the shift: Consolidating care activities, rather than spreading them out, minimizes interruptions and helps reduce sensory input.
D. Keep the door to the client's room open: Keeping the door open can increase noise and stimuli, exacerbating sensory overload.
Correct Answer is A
Explanation
A. "Use written communication to supplement verbal instructions and ensure the client understands the information." Written communication supports understanding, especially when hearing impairment may limit verbal communication.
B. "Use gestures and non-verbal cues only, without speaking, as the client is able to read lips effectively." Lip reading alone is insufficient for most hearing-impaired clients. Combining gestures, speech, and written communication is more effective.
C. "Avoid standing in front of the client while speaking." Standing in front of the client is crucial to ensure visibility for lip-reading or interpreting gestures.
D. "Speak loudly and slowly to the client to ensure they can hear you clearly." Speaking too loudly may distort sounds, and slow speech does not always enhance comprehension. Instead, normal tone and clear enunciation are recommended.
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