An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying.
What interventions should the nurse include in this client’s plan of care? Select all that apply.
Teach the client how to use guided imagery
Instruct the client and family to reconsider end of life choices
Record the client’s desire to live
Encourage the family to bring the client old photographs
Encourage the family to visit frequently .
Correct Answer : A,D,E
Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.
Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.
Correct Answer is ["A","B","C","F"]
Explanation
The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.
Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.
Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).
Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.
Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.
Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.
Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.
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