The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Check skin for unusual bruising.

Palpate mucus membranes for cracks.

Monitor color of nailbeds.

Assess skin folds of perineal area.

Observe skin under the breasts.

Answer and Explanation

Correct Answer : D,E

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Explain that alternative treatment options may be helpful. B. Offer reassurance that the spouse is not alone. C. Encourage the spouse to share their feelings. D. Remind the spouse that the client may still live a long time.

Correct Answer is C

Explanation

A. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.

B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.

C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.

D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.

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The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is C

Explanation

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