Exhibits
Complete the following sentence by using the list of options.
Mrs. Thompson is at high risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.
Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.
Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.
Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.
Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.
Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.
End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A"}
Explanation
The most likely cause of the client’s condition based on the nurse’s observation is potential physical abuse and neglect by the caregiver.
Potential physical abuse and neglect by the caregiver. The presence of bruises in various stages of healing, malnutrition, poor hygiene, and fearful behavior suggests possible elder abuse and neglect. The caregiver’s agitation when questioned further raises suspicion. The nurse should follow facility protocols and report concerns to appropriate authorities for further investigation.
Medications that cause spontaneous bruising and skin changes in elderly individuals. While aspirin can increase the risk of bruising, it does not explain the signs of malnutrition, poor hygiene, and fearful behavior. These additional findings suggest a broader concern beyond medication side effects.
Poor dietary intake and lack of proper medical care due to the client's advanced age and disease. While dementia and heart disease can contribute to nutritional challenges, they do not account for unexplained bruising, fearfulness, or a caregiver’s defensive behavior. Malnutrition in this case is more likely due to neglect rather than disease progression.
Chronic illness leading to frailty and easy bruising. Chronic illnesses can make elderly individuals more vulnerable to bruising and weakness, but they do not explain poor hygiene, malnutrition, or the client's fearful demeanor, which are more indicative of abuse or neglect.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse identifies that the client is currently in Kübler-Ross's anger stage of grief as evidenced by feeling like life is not fair.
Anger. In this stage, individuals express frustration, resentment, or questioning of fairness. The client’s statement, "Why is this happening to me? I have always been healthy," reflects anger and a sense of injustice regarding their diagnosis. The refusal of medications and care further supports emotional distress and resistance.
Denial and Isolation. This stage is characterized by disbelief regarding the diagnosis or refusal to accept reality. On Day 1, the client questioned the accuracy of their test results, suggesting denial. However, by Day 3, their emotions had shifted to frustration, making denial no longer the most fitting condition.
Bargaining. This stage involves making deals with a higher power or attempting to negotiate for more time or a different outcome. The client has not displayed behaviors indicative of bargaining, such as promising to change habits or seeking alternative treatments.
Acceptance. Acceptance is marked by established methods of coping and coming to terms with the diagnosis. The client is still struggling emotionally, refusing care, and expressing frustration, which indicates they have not yet reached this stage.
Depression. This stage is characterized by feelings of deep sadness for potential missed experiences. The client’s emotional response is more aligned with anger rather than deep sorrow, withdrawal, or despair, which are typical signs of depression in the grieving process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.