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

Keep mucous membranes moist.

Record the client's daily weight.

Maintain in high Fowler's position.

Report any change in urine color.

Answer and Explanation

The Correct Answer is A

A. Keeping the mucous membranes moist is essential for comfort and preventing discomfort associated with dryness, especially in a client who is weak and mouth breathing. This intervention can help prevent issues such as dry mouth, cracked lips, and irritation of the oral mucosa, which can contribute to discomfort and difficulty swallowing.
B.   Monitoring the client's weight can provide valuable information about fluid balance and nutritional status but in the context of a terminally ill client who is weak and refusing to eat or drink, daily weight monitoring may not be as relevant or informative.
C.   The high Fowler's position is often used to improve breathing comfort and lung expansion in clients experiencing respiratory distress. However, in a terminally ill client who is weak and mouth breathing, maintaining them in a high Fowler's position may not be necessary or comfortable.

D.   While monitoring urine output and characteristics is important for assessing renal function and hydration status, changes in urine color may not be a priority in the care of a terminally ill client who is weak and not consuming fluids.

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Correct Answer is A

Explanation

A. Encouraging the client to visualize positive external places, such as peaceful landscapes, serene beaches, or tranquil gardens, can help distract from the pain and promote relaxation. This focus can help shift the client's attention away from the pain sensation, potentially reducing its intensity and improving overall comfort.
B. Tranquil sounds can be utilized but are not a form of guided imagery.

C. Emotional reflection (choice C) may not directly contribute to pain relief during guided imagery sessions.
D. Incorporating motivational phrases during guided imagery can help boost the client's mood, enhance self-confidence, and foster a positive mindset, which may contribute to pain relief and overall well- being. However, positive external places should be the primary focus.

A. if the popsicles are completely frozen. B. How many popsicles are available. C. The color and flavor of gelatin used. D. Whether they contain pulp or fruit.

Correct Answer is A

Explanation

A. If the popsicles are completely frozen. This is the most crucial information in this scenario. Clear liquids are recommended for a child who has been vomiting, and if the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child's condition.
B. Knowing the quantity of popsicles available can help the nurse assess the child's potential intake of fluids and ensure that an adequate supply is on hand if needed.
C. The color and flavor of gelatin used is important because certain colors and flavors of gelatin may contain additives or artificial ingredients that could potentially worsen the child's condition or cause discomfort.
D. While it’s important that clear liquids do not contain pulp or solid materials, in this scenario, the immediate concern is the state of the popsicles (frozen or not) rather than their composition.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is A

Explanation

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