A nurse is preparing to care for a client on the medical unit.
Complete the following sentence by using the lists of options. The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Correct answers:
1. pulmonary edema
2. shallow rapid breaths
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.
B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.
C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.
D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.
Correct Answer is A
Explanation
A. Administer scheduled pain medications is appropriate because providing comfort is a priority in end-of-life care. Administering scheduled pain medications helps alleviate any discomfort or pain the client may be experiencing.
B. Providing oral care every 6 hr may not be necessary in the end-of-life stage, as the client's ability to tolerate oral care may decrease, and excessive oral care may cause discomfort.
C. Administering liquids using a syringe may not be appropriate if the client is unable to swallow or if there are concerns about aspiration.
D. Whispering when talking to family members is not necessary; instead, the nurse should communicate in a calm and clear manner, adjusting the volume and tone as needed to accommodate the client's condition and preferences.
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