The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

Restlessness

Decreased appetite

Skin pallor

Anuria

Answer and Explanation

The Correct Answer is D

A. Restlessness: This may occur in the pre-active phase of dying but is not specific to the actively dying phase.

B. Decreased appetite: A reduced appetite is common earlier in the dying process, not specific to the actively dying phase.

C. Skin pallor: Skin changes, such as pallor, occur earlier; mottling is more indicative of the actively dying phase.

D. Anuria: Anuria (absence of urine output) is a hallmark sign of multisystem failure and the actively dying phase.

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Correct Answer is A

Explanation

A. “Brain death has occurred if there is no spontaneous breathing or brainstem reflexes.” Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of spontaneous breathing and brainstem reflexes (such as pupillary response, gag reflex, and eye movements) are critical criteria used to confirm brain death.

B. “If respiratory efforts cease and no apical pulse is audible, brain death is present.” While the cessation of respiratory efforts is a key component of brain death, the presence or absence of an apical pulse alone is not sufficient for determining brain death. Brain death is determined based on the complete absence of brain function, including brainstem reflexes.

C. “Brain death has occurred if a person has flaccid muscles and does not awaken.” Muscle flaccidity and lack of consciousness may be signs of severe brain injury, but they do not necessarily confirm brain death. Brain death is diagnosed based on the absence of brainstem reflexes and spontaneous breathing.

D. “CPR does not restore a heartbeat, the brain cannot function.” While it is true that CPR may not restore circulation in brain-dead patients, this statement is incomplete and not a precise definition of brain death. Brain death is determined by the irreversible cessation of all brain activity, not just by the failure of CPR to restore circulation.

A. Bring the crash cart to the bedside B. Start Cardiopulmonary resuscitation. C. Defibrillate the client D. Administer Adenosine (Adenocard) to assist in determining the patient's rhythm E. Consider the "Hs and Ts" (reversible causes of cardiac arrest) to determine appropriate treatment.

Correct Answer is ["A","B","C","E"]

Explanation

A. Bring the crash cart to the bedside: Essential for advanced cardiac life support (ACLS), including defibrillation and medications.

B. Start cardiopulmonary resuscitation: High-quality CPR is critical to maintain circulation until defibrillation can occur.

C. Defibrillate the client: Defibrillation is the definitive treatment for ventricular fibrillation to restore a normal rhythm.

D. Administer adenosine (Adenocard) to assist in determining the rhythm: Adenosine is used for diagnosing or treating certain supraventricular tachycardias, not ventricular fibrillation.

E. Consider the "Hs and Ts": Identifying reversible causes of cardiac arrest (e.g., hypoxia, hypothermia, toxins) is part of the ACLS protocol.

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The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","E"]

Explanation

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