The nurse caring for a terminally ill patient sits down and lightly touches the patient’s hand. Which technique is the nurse using?

Providing health promotion.

Offering transcendence.

Establishing presence.

Doing for.

Answer and Explanation

The Correct Answer is C

Choice A reason: Health promotion involves teaching lifestyle changes, not physical touch or emotional support, as seen here. Presence focuses on being with the patient empathetically. Assuming health promotion misaligns with the action, risking neglect of the patient’s emotional and spiritual needs, critical for comfort in terminal illness care settings.

Choice B reason: Offering transcendence involves fostering spiritual meaning, not physical touch or presence. The nurse’s hand-touching establishes emotional connection, not existential exploration. Assuming transcendence overlooks the relational aspect of presence, potentially missing the patient’s immediate need for comfort and connection in the context of terminal illness care.

Choice C reason: Establishing presence involves being physically and emotionally available, as shown by sitting and touching the patient’s hand. This empathetic connection, rooted in Watson’s caring theory, fosters comfort and trust, critical for terminally ill patients. Presence supports emotional well-being, ensuring holistic care and dignity in end-of-life situations.

Choice D reason: Doing for involves performing tasks like bathing, not emotional support through touch. The nurse’s action establishes presence, not task-oriented care. Assuming doing for risks misinterpreting the action, potentially neglecting the patient’s need for empathetic connection, essential for psychological comfort in terminal illness care.

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Correct Answer is A

Explanation

Choice A reason: Obstructive sleep apnea causes airway collapse, leading to hypopnea, apnea, and hypoxia. Assessing respiratory status, including oxygen saturation, respiratory rate, and snoring, is critical to detect life-threatening desaturations or respiratory failure. This priority ensures airway patency and adequate oxygenation, addressing the primary pathophysiology of the condition.

Choice B reason: Neurological function may be affected by hypoxia in severe sleep apnea, causing daytime sleepiness or cognitive issues. However, respiratory status is the priority, as airway obstruction directly threatens oxygenation. Neurological assessment is secondary, as it does not address the immediate risk of respiratory compromise.

Choice C reason: Circulatory status, like blood pressure, may be impacted by chronic sleep apnea due to hypoxia-induced hypertension. However, respiratory status takes precedence, as airway obstruction is the primary issue causing desaturation. Circulatory changes are secondary and less urgent than ensuring adequate ventilation.

Choice D reason: Gastrointestinal function is unrelated to obstructive sleep apnea’s primary effects. While reflux may contribute to sleep issues, it is not a priority compared to respiratory status, which

A. Place the patient in the room farthest from the nurses’ station. B. Ask the patient “Would you like a newspaper to read?” C. Offer the patient a back rub. D. Hang a “Do not disturb” sign on patient’s door.

Correct Answer is B

Explanation

Choice A reason: Placing the patient farthest from the nurses’ station increases isolation, worsening sensory deprivation. Bed rest already limits stimuli, and distance reduces interaction with staff, exacerbating disorientation or loneliness. This action contradicts the need to provide sensory stimulation, making it an incorrect choice.

Choice B reason: Asking if the patient wants a newspaper provides visual and cognitive stimulation, counteracting sensory deprivation from bed rest. Reading engages the mind, reducing boredom and disorientation. This action aligns with promoting sensory input, making it an appropriate intervention to maintain mental engagement and well-being.

Choice C reason: Offering a back rub provides tactile stimulation, which is beneficial, but sensory deprivation primarily affects cognitive and perceptual functions. Reading a newspaper better addresses visual and intellectual needs, more directly countering the effects of limited environmental stimuli, making this a less optimal choice.

Choice D reason: Hanging a “Do not disturb” sign reduces interactions, increasing sensory deprivation. Bed rest patients need regular engagement to prevent disorientation or depression. This action isolates the patient further, contradicting the goal of providing sensory stimulation, making it an incorrect intervention.

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The nurse caring for a terminally ill patient sits down and lightly touches the patient’s hand. Which technique is the nurse using?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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