The nurse is assessing a terminally ill client who is on home hospice care and notes that the client is demonstrating signs of terminal delirium and becoming more unresponsive. Which of the following instructions should the nurse give to the client’s children?
"We recommend that you sit at your parent's bedside so you can document the time of death."
"Limit the amount of environmental noise in your parent's room to decrease stimulation."
"This may be very difficult for you to watch your parent, so take some respite time to re-charge."
"Family often uses this time to tell their parent that it is okay to let go."
The Correct Answer is B
A. Documenting the time of death is not an immediate concern during the process of terminal delirium and does not directly address the patient's comfort.
B. Limiting environmental noise helps reduce stimulation, which can be beneficial for a patient experiencing terminal delirium and unresponsiveness, helping to maintain a calm environment.
C. While taking respite time may be necessary for family members, it does not directly address the needs of the patient with terminal delirium.
D. Telling the patient it is okay to let go is emotionally supportive but does not address the immediate need to manage symptoms and provide comfort during terminal delirium.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Although thyroid cancer and medication use can affect health, they are not the most immediate factors influencing fall risk compared to heart failure symptoms.
B. Diabetes mellitus and metformin use are not directly associated with increased fall risk as much as heart failure and its symptoms.
C. Decompensated heart failure and dyspnea on exertion significantly increase fall risk due to decreased physical stability and balance issues.
D. While hypertension and lisinopril can contribute to fall risk, they are less directly impactful than the symptoms of decompensated heart failure.
Correct Answer is B
Explanation
A. While creating personalized meal plans is an important task for a dietitian, it does not reflect the interprofessional collaboration often seen in community health settings, where multiple disciplines work together.
B. A team involving a nurse, social worker, and community health worker exemplifies effective interprofessional care, as it shows collaboration among different professionals to address a complex issue such as homelessness.
C. Medication counseling by a pharmacist is a key component of healthcare but is generally considered part of the pharmacist's role rather than interprofessional collaboration.
D. Blood pressure screenings by a nurse are valuable but represent an individual effort rather than a collaborative, interprofessional approach to community health.
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