An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gas results indicate hypoxia. Which intervention is most important for the nurse to implement?
Clarify end of life desires.
Offer sips of favorite beverages.
Initiate comfort measures.
Prepare for emergent oral intubation.
The Correct Answer is C
A. Clarify end of life desires: While understanding a client’s goals is vital, this may not address her immediate needs. The client is already showing signs of distress and hypoxia, so initiating comfort measures promptly is more urgent than discussing future preferences.
B. Offer sips of favorite beverages: Offering fluids may help with oral comfort but does not address the client’s respiratory distress or overall suffering. It is a low-priority intervention in the setting of acute hypoxia and confusion related to terminal illness.
C. Initiate comfort measures: Comfort measures are the priority for a terminally ill client with hypoxia and confusion who is refusing food and expressing a wish to go home. This aligns care with the client's likely stage in the dying process and ensures symptom relief over aggressive interventions.
D. Prepare for emergent oral intubation: Intubation is invasive and likely inconsistent with palliative goals in end-stage cancer. Without clear patient consent or indication that life-prolonging measures are desired, focusing on comfort is more appropriate and ethical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.
B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.
C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.
D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.
Correct Answer is B
Explanation
A. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: There are no cures for Parkinson's disease, and suggesting that alternative treatments could cure it could create unrealistic expectations.
B. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: This response provides accurate information while being honest about the limitations of current treatments for Parkinson's disease.
C. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or conventional medications currently cure Parkinson’s disease. The nurse should avoid suggesting potential cures that are not based on scientific evidence.
D. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While this may be supportive for the wife, it does not directly address her question about treatment options. The focus should be on providing accurate information regarding the disease and treatment options.
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