A nurse is reinforcing teaching with a guardian about manifestations of the impending death of a child. Which of the following manifestations should the nurse include?
Urinary frequency
Difficulty swallowing
Decreased sleep
Increased senses
The Correct Answer is B
Rationale:
A. Urinary frequency: As death approaches, urinary output typically decreases due to reduced kidney perfusion. Urinary frequency is not a common sign of impending death and may suggest other unrelated conditions.
B. Difficulty swallowing: Difficulty swallowing is a common manifestation of impending death. As muscle tone declines, the child may struggle to manage secretions or food, increasing the risk of aspiration and signaling the body is shutting down.
C. Decreased sleep: Clients nearing death often exhibit increased sleep or lethargy, not decreased sleep. Diminished responsiveness and longer periods of unresponsiveness are expected in the final stages of life.
D. Increased senses: Sensory function generally declines as death nears. Vision, hearing, taste, and touch may all diminish, and the child may become less responsive to external stimuli. Increased senses are not expected at this stage
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Contact security personnel to place the money in the designated secure location: Hospitals have protocols for handling client valuables. The safest and most appropriate action is to notify security so the funds can be securely stored, documented, and returned appropriately. This maintains accountability and protects both the client and staff.
B. Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.
C. Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.
D. Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.
Correct Answer is D
Explanation
Rationale:
A. Plan time to complete the task: While the nurse may need to complete the task if it remains undone, doing so without first addressing the AP’s refusal overlooks a potential communication or training issue and does not resolve the underlying problem.
B. Assign the task to another AP: Reassigning the task without understanding the reason for refusal may perpetuate noncompliance and disrupt team dynamics. It is important to first clarify why the AP is unwilling before redirecting the task.
C. Notify the charge nurse immediately: Escalating to the charge nurse is appropriate if the issue cannot be resolved directly. However, the first action should be to attempt communication and resolution with the AP to encourage accountability and collaboration.
D. Discuss the AP's concerns about the task: This is the most appropriate initial response. By opening a discussion, the nurse can identify whether the refusal stems from a misunderstanding, lack of training, or legitimate concern, allowing for timely correction or education.
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