The nurse is performing an initial assessment on a patient with respiratory difficulty. The nurse would anticipate documenting signs and symptoms such as:

excessive dryness.

regular respiratory pattern.

use of accessory muscles.

alteration in sensation.

Answer and Explanation

The Correct Answer is C

A. Excessive dryness: This is not a primary sign of respiratory difficulty.

B. Regular respiratory pattern: A regular pattern is indicative of normal respiration, not difficulty.

C. Use of accessory muscles: Accessory muscle use is a hallmark sign of respiratory distress, indicating increased effort to breathe.

D. Alteration in sensation: This is more associated with neurological conditions rather than respiratory issues.

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Correct Answer is ["A","D","E"]

Explanation

A. Time vital signs ceased. Documenting the time at which vital signs ceased is important for medical and legal documentation. This helps establish the timeline of events leading to death and can be relevant for determining the official time of death.

B. Results of the autopsy. While an autopsy may provide valuable information, it is not typically documented at the time of death unless available. Autopsy results are generally included later after they are completed, not immediately after death.

C. Why the patient died. While the cause of death is often determined, it is generally not the nurse's role to speculate or document the reason for death in the medical record at the time of death. It is more appropriate for the physician or coroner to document the cause.

D. Official time of death. The official time of death should be documented as this is critical for legal, medical, and procedural purposes. It is typically recorded when the attending physician or another authorized individual pronounces the death.

E. Who pronounced the patient. It is necessary to document who pronounced the patient deceased to ensure that the pronouncement of death is legally recognized. This is part of standard medical documentation and ensures proper identification of the responsible party.

A. Listen to the patient, answer questions, and offer to have the supervisor or physician speak with the patient. B. Call both the supervisor and a family member to try to get the patient to reconsider. C. Obtain a written explanation of the reasons from the patient and have the patient sign at the bottom of the sheet. D. Advise the patient that this may mean that insurance would not pay for this hospitalization.

Correct Answer is A

Explanation

A. Listen to the patient, answer questions, and offer to have the supervisor or physician speak with the patient. Understanding the patient’s concerns and providing information may help address their reasons for leaving and promote informed decision-making. Involving the supervisor or physician allows for further discussion.

B. Call both the supervisor and a family member to try to get the patient to reconsider: Family involvement should only occur with the patient’s consent.

C. Obtain a written explanation of the reasons from the patient: This can be done after addressing the patient’s concerns.

D. Advise the patient that insurance may not pay for this hospitalization: This may seem coercive and is not an immediate priority.

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The nurse is performing an initial assessment on a patient with respiratory difficulty. The nurse would anticipate documenting signs and symptoms such as:

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Naxlex Comprehensive Predictor Exams

A patient dies after suffering a severe cerebrovascular accident (CVA). The family members are informed of his demise and are at the bedside. What documentation should be noted in the patient's medical record? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A hospitalized patient tells the nurse that he intends to leave the acute care facility, against medical advice. The nurse's initial action(s) should be to:

Correct Answer is A

Explanation

A nurse who was present at the time of the death of a patient should document:

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