A nurse is providing palliative care to a client who is receiving hospice care and is approaching death. Which of the following actions should the nurse take? (Select all that apply.)
Do not force the client to stay awake
Administer pain medication by rectal or transdermal when client can no longer swallow
Position the client on her side
Offer to turn and reposition client every 2 hours
Correct Answer : A,B,C,D
A. Do not force the client to stay awake: Palliative care focuses on providing comfort and dignity to the patient, and forcing the client to stay awake would not align with this goal. Allowing the client to rest as needed is essential for maintaining comfort during the end-of-life process.
B. Administer pain medication by rectal or transdermal when client can no longer swallow: As the client approaches death, they may lose the ability to swallow oral medications. Administering pain medication rectally or via transdermal patches ensures that the client continues to receive adequate pain relief even when oral intake is no longer possible.
C. Position the client on her side: Positioning the client on her side helps prevent aspiration if there is vomiting and promotes comfort by reducing pressure on bony prominences. This position also facilitates effective airway management and can help alleviate respiratory distress.
D. Offer to turn and reposition client every 2 hours: Turning and repositioning can help prevent pressure ulcers and maintain skin integrity, during the terminal stage of illness. The frequency of turning and repositioning may be adjusted based on the client's comfort and clinical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Provide laxatives and stool softeners to prevent constipation (Option A): While constipation may be a concern for immobile patients, there is no indication in the scenario that the patient is currently experiencing constipation. Therefore, providing laxatives and stool softeners would not be a priority at this time.
Provide him with an air pressure mattress (Option B): This option is appropriate because the patient is immobile and at risk of developing pressure ulcers due to prolonged bed rest. An air pressure mattress helps distribute pressure evenly and reduces the risk of pressure ulcer formation, which is crucial for maintaining skin integrity and preventing complications.
Coax him to eat high-calorie, high-fat food (Option C): Although the patient is experiencing weight loss due to poor nutrition, coaxing him to eat high-calorie, high-fat food may not be appropriate if he is experiencing nausea and anorexia. This approach may exacerbate gastrointestinal symptoms and discomfort.
Contact the primary care provider for an order for tube feeding (Option D): While tube feeding may be considered if the patient is unable to meet his nutritional needs orally, it should not be the first intervention. Before considering tube feeding, other options for improving oral intake and addressing nausea and anorexia should be explored. Additionally, tube feeding may not address the patient's immobility and risk of pressure ulcers. Therefore, providing an air pressure mattress is a more appropriate intervention in this scenario.
Correct Answer is C
Explanation
A. Bereavement: Bereavement refers to the period of mourning and adjustment that follows the loss of a loved one. It encompasses the range of emotions and behaviors experienced after a death.
B. Depression: Depression is a mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities. While grief can manifest as symptoms of depression, they are distinct concepts.
C. Grief: Grief is the emotional response to loss, encompassing a range of feelings such as sadness, anger, guilt, and despair. It is a natural and adaptive reaction to the death of a loved one or other significant losses.
D. Sadness: Sadness is a transient emotional state characterized by feelings of sorrow, unhappiness, or low spirits. While sadness is often a component of grief, grief involves a broader range of emotional responses to loss.
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