After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.
The family wish to see the body before it is taken to the funeral home.
Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).
Take out dentures and place in a labeled cup.
Gently close the eyes.
Place a small pillow under the head.
Apply a body shroud.
Remove resuscitation equipment from the room.
Correct Answer : B,C,D,E
The correct answers are Choices B, C, D, and E.
Choice A rationale: Dentures should remain in place to preserve facial structure and dignity. Removing them may cause facial collapse, distressing the family during viewing and violating postmortem presentation standards.
Choice B rationale: Gently closing the eyes prevents ocular drying and maintains a peaceful appearance. If eyelids resist closure, moistened cotton balls may be used temporarily to assist with natural positioning.
Choice C rationale: Placing a small pillow under the head elevates it, preventing blood pooling and facial discoloration due to livor mortis. It supports a natural, respectful presentation for family viewing.
Choice D rationale: Applying a body shroud ensures hygienic containment and visual dignity. It’s standard practice before transport and aligns with institutional protocols for respectful postmortem care.
Choice E rationale: Removing resuscitation equipment reduces trauma triggers for the family, restores environmental calm, and supports emotional closure. It also complies with facility standards for postmortem room preparation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,C,A
Explanation
Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.
2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.
3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.
4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.
Correct Answer is B
Explanation
Choice A rationale:
CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.
Choice B rationale:
Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
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