A nurse is documenting end-of-life care. Which information will the nurse include in the patient’s electronic medical record? (Select all that apply)

Time of body transfer and destination.

Special preparations of the body.

Time and date of death.

Location of body identification tags.

Reason for the death.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: Documenting the time of body transfer and destination ensures accurate tracking of the deceased, maintaining chain of custody and compliance with legal and hospital protocols. This information supports coordination with morgue or funeral services, preventing errors in body handling and ensuring respectful, organized end-of-life care per regulatory standards.

Choice B reason: Special preparations, like cleaning or cultural rituals, must be documented to reflect respectful care aligned with patient or family wishes. This ensures continuity of care, legal compliance, and sensitivity to cultural or religious practices, preventing oversight of specific requests and supporting dignified handling of the deceased in medical records.

Choice C reason: Time and date of death are critical for legal and medical documentation, establishing the official record required for death certificates and hospital reporting. Accurate recording ensures compliance with regulations, supports family closure, and prevents discrepancies in legal or insurance processes, making it essential in end-of-life care documentation.

Choice D reason: Location of body identification tags is documented to ensure proper identification, preventing errors during transfer or postmortem procedures. This complies with hospital policies and legal standards, ensuring traceability and respect for the deceased. Accurate tagging documentation supports safe, organized handling, critical for ethical end-of-life care management.

Choice E reason: Reason for death may be noted by physicians but is not typically required in nursing end-of-life documentation unless specified. Nurses focus on procedural details like time of death or body preparation. Including this risks role confusion, as determining cause is a medical responsibility, potentially leading to inaccurate or incomplete nursing records.

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Correct Answer is B

Explanation

Choice A reason: Maturational loss occurs with normal developmental transitions, like aging or menopause. Amputation from military injuries is an unexpected event, not a developmental milestone. This type does not apply to the veteran’s sudden, trauma-related loss, making it incorrect for the care plan focus.

Choice B reason: Situational loss results from unpredictable events, like amputation due to military injuries. This loss impacts the veteran’s mobility, identity, and lifestyle, requiring targeted interventions for grief, adaptation, and rehabilitation. The nurse’s care plan should focus on addressing this situational loss to support emotional and physical recovery.

Choice C reason: Perceived loss is subjective, like loss of self-esteem, but amputation is a tangible, objective loss of limbs. While emotional impacts exist, the primary loss is physical and situational. This type is less specific to the veteran’s experience, making it an incorrect focus for the care plan.

Choice D reason: Uncomplicated loss refers to normal grief without complications, not a specific type of loss. Amputation is a complex situational loss with physical and psychological impacts. This term does not capture the nature of the veteran’s experience, making it inappropriate for the care plan focus.

A. The patient is difficult to awaken. B. The patient’s vital signs are elevated. C. The patient awakens easily. D. The patient’s eyes rapidly move.

Correct Answer is A

Explanation

Choice A reason: Stage 4 NREM (deep sleep) is characterized by slow delta brain waves, making the patient difficult to awaken. This stage promotes physical restoration, with minimal responsiveness to stimuli. The assessment finding aligns with the physiological state of deep sleep, making it the correct indicator for stage 4 NREM.

Choice B reason: Elevated vital signs are not typical of stage 4 NREM, where metabolic rate and heart rate decrease due to deep relaxation. Elevated vital signs may occur in REM or lighter sleep stages, making this finding inconsistent with the characteristics of deep NREM sleep.

Choice C reason: Easily awakening occurs in lighter NREM stages (1 or 2), not stage 4, which is the deepest sleep phase. Patients in stage 4 require significant stimuli to rouse, so this finding contradicts the expected state of deep sleep, making it incorrect.

Choice D reason: Rapid eye movement is specific to REM sleep, not NREM. Stage 4 NREM involves slow brain waves and no eye movement, focusing on physical restoration. This finding is characteristic of a different sleep phase, making it an incorrect indicator for stage 4 NREM.

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A nurse is documenting end-of-life care. Which information will the nurse include in the patient’s electronic medical record? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

Correct Answer is B

Explanation

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

Correct Answer is A

Explanation

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