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 ["A","D","E"]
Explanation
A. Use pictures. Visual aids enhance comprehension, especially for clients with limited English proficiency. Pictures, diagrams, and illustrations help convey important information when language barriers exist.
B. Use materials written at a twelfth-grade level. This is inappropriate because most health education materials should be written at a fifth- to sixth-grade reading level to ensure accessibility. Higher reading levels may be too complex for many clients, particularly those with limited health literacy.
C. Provide a variety of educational materials. While multiple formats (e.g., videos, pamphlets) can be helpful, simply offering a variety does not ensure comprehension. The materials must be tailored to the client’s language and literacy level.
D. Choose materials that include culturally relevant information and examples. Cultural relevance improves engagement and understanding. Materials should reflect the client’s cultural background, beliefs, and values to make the information more meaningful.
E. Use materials written in the client's spoken language. Providing materials in the client’s primary language ensures better understanding. When possible, professional medical interpreters should also be used to clarify any uncertainties.
Correct Answer is A
Explanation
A. Listen actively and attentively to the client and family concerns and emotions. Active listening is the most important action at the end-of-life stage. The client and family may have fears, emotional distress, or unanswered questions, and the nurse should provide empathetic support and reassurance. Listening fosters trust, emotional comfort, and dignity in care.
B. Encourage the client to make decisions about treatment options and advance care planning. While advance care planning is important, Mrs. Thompson has already expressed her wishes and designated decision-makers. At this stage, the focus should be on comfort rather than making new treatment decisions.
C. Provide detailed medical information and prognosis to the client. While some information may be appropriate, overloading the client with medical details may increase stress. The nurse should provide information as needed but prioritize emotional support.
D. Discuss funeral arrangements and end-of-life wishes with the client. This may be appropriate if the client initiates the conversation, but forcing discussions about funeral plans may not be beneficial. The nurse’s role is to support emotional well-being rather than focus on logistics.
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