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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This response is compassionate and invites the client to share their feelings. The gentle touch on the forearm can convey empathy and support, but it’s important to ensure that physical contact is appropriate for the client. This option encourages open communication while respecting the client’s feelings.

B.While this response acknowledges the client's distress, it also dismisses their feelings by suggesting that the assessment can be postponed. This can make the client feel invalidated or that their emotions are not important enough to address immediately.
C. This offers physical comfort and reassurance, but again, the nurse must be mindful of the client's boundaries and preferences regarding physical contact.
D. Recognizes the client's distress and offers to return later, which might be appropriate if the client prefers to be alone. However, this option fails to offer an opportunity for support to the client.

A. Share personal values to put the client at ease. B. Ask questions in a vague, nonspecific format. C. Get the most difficult questions over with first. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

D. Starting with less sensitive questions allows the nurse to establish rapport with the client and create a comfortable environment before addressing more sensitive topics. This approach helps build trust and encourages the client to open up about their concerns regarding sexual activity.
A. Sharing personal values may not be appropriate as it could potentially introduce bias or make the client feel uncomfortable if their values differ from those of the nurse.
B. Asking vague or nonspecific questions may result in incomplete or unclear information from the client, leading to ineffective assessment and care planning.
C. Starting with the most difficult questions may cause the client to feel overwhelmed or defensive, hindering open communication.

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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

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