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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Acute stress disorder occurs within one month of trauma, with symptoms like nightmares and dissociation. However, symptoms persisting beyond one month, as in this case, indicate PTSD. The patient’s presentation aligns with chronic trauma effects, making PTSD the more likely diagnosis over acute stress disorder.
Choice B reason: General adaptation syndrome describes the body’s physiological response to stress (alarm, resistance, exhaustion). It is not a psychiatric diagnosis and does not account for trauma-specific symptoms like nightmares or emotional numbing. This is unrelated to the patient’s psychological response, making it incorrect.
Choice C reason: PTSD is characterized by persistent symptoms beyond one month post-trauma, including nightmares, intrusive memories, avoidance, and emotional numbing, matching the patient’s presentation. Sexual assault is a common trigger, and the nurse would expect this diagnosis documented due to the chronicity and specificity of symptoms.
Choice D reason: Alarm reaction is the initial phase of general adaptation syndrome, involving acute stress response like fight-or-flight. It is not a diagnosis and does not explain chronic psychological symptoms like recurrent memories or emotional detachment, making it irrelevant to the patient’s trauma-related condition.
Correct Answer is B
Explanation
Choice A reason: Pre-sleep, the transition to sleep, is not a distinct sleep cycle stage and varies widely, not consistently lasting 10-30 minutes. NREM Stage 2 has a defined duration. Misidentifying pre-sleep risks confusing staff, potentially leading to inaccurate sleep assessments and interventions in patients with sleep disorders.
Choice B reason: NREM Stage 2, lasting 10-30 minutes per cycle, involves light sleep with sleep spindles and K-complexes, consolidating memory and transitioning to deeper sleep. Accurate teaching ensures staff recognize this stage’s role in restorative sleep, guiding monitoring and interventions for patients with disrupted sleep patterns in clinical settings.
Choice C reason: REM sleep, lasting 10-20 minutes initially but up to 60 minutes later in the night, does not consistently fall within 10-30 minutes. NREM Stage 2 is more accurate. Misidentifying REM risks staff misunderstanding sleep cycles, potentially affecting sleep assessments and management in patients with insomnia or neurological conditions.
Choice D reason: NREM Stage 1, lasting 5-10 minutes, is shorter than 10-30 minutes, involving light sleep and easy arousability. NREM Stage 2 better fits the duration. Misidentifying Stage 1 confuses sleep cycle education, risking inaccurate monitoring and interventions for sleep quality, critical for patient recovery and health outcomes.
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