The patient has a terminal diagnosis and is very near death. When the nurse assesses the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating?
Caring touch
Therapeutic touch
Task-oriented touch
Protective touch
The Correct Answer is D
Choice A reason: Caring touch involves physical contact to convey empathy, like holding a hand. The nurse leaves the room without touching the patient or family, overwhelmed by grief. This action does not involve physical contact or comfort, making it unrelated to caring touch in this scenario.
Choice B reason: Therapeutic touch is a healing technique using energy fields, not applicable here. The nurse’s departure due to emotional overwhelm does not involve physical or energetic interaction with the family or patient, focusing instead on self-preservation, making this an incorrect type of touch.
Choice C reason: Task-oriented touch involves physical contact for procedures, like taking a pulse. The nurse’s action of leaving the room is not task-related or physical. It reflects an emotional response to grief, not a clinical task, making this an incorrect description of the nurse’s behavior.
Choice D reason: Protective touch describes actions to shield oneself or others from emotional distress, like withdrawing from overwhelming situations. The nurse, overwhelmed by the family’s grief, leaves the room to cope, demonstrating protective touch by prioritizing emotional self-preservation, making this the correct description.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Self-care deficit addresses physical inability to perform daily tasks, not psychological issues from sensory impairments. Hearing and visual loss primarily impact communication, leading to socialization issues. Assuming self-care deficit misaligns the diagnosis, risking neglect of psychological needs like social isolation, critical for mental health in sensory-impaired patients.
Choice B reason: Risk for falls is a physical safety concern due to sensory impairments but not psychological. Impaired socialization better addresses the psychological impact of communication barriers. Prioritizing falls risks overlooking social isolation, delaying interventions like communication aids, essential for mental well-being in patients with hearing and visual deficits.
Choice C reason: Impaired socialization, a psychological nursing diagnosis, reflects the communication barriers from hearing and visual impairments, leading to social isolation and emotional distress. This diagnosis guides interventions like assistive devices or support groups, critical for mental health, ensuring patients maintain social connections and emotional resilience despite sensory challenges.
Choice D reason: Impaired physical mobility relates to movement limitations, not psychological effects of sensory impairments. Hearing and visual loss primarily cause socialization issues, not mobility deficits. Assuming mobility misdirects care, neglecting psychological needs like social engagement, critical for preventing isolation and supporting mental health in sensory-impaired patients.
Correct Answer is D
Explanation
Choice A reason: Short naps (15-20 minutes) are recommended for narcolepsy to manage excessive daytime sleepiness without disrupting nighttime sleep. This aligns with evidence-based management, improving alertness. No intervention is needed, as this practice supports symptom control, enhancing daily function and reducing sleep attacks in narcolepsy patients.
Choice B reason: Taking antidepressants, like SSRIs or SNRIs, is standard for narcolepsy to manage cataplexy or sleep disturbances. This is appropriate and requires no intervention unless misuse occurs. The nurse would ensure proper dosing, as antidepressants support symptom control, improving quality of life without disrupting narcolepsy management strategies.
Choice C reason: Chewing gum regularly is benign and unrelated to narcolepsy management. It may help with alertness but doesn’t warrant intervention. Unlike environmental factors like room temperature, gum has no significant impact on sleep quality or narcolepsy symptoms, making it an irrelevant focus for nursing education or correction.
Choice D reason: Sleeping in a hot, stuffy room disrupts sleep quality, exacerbating narcolepsy symptoms like fragmented sleep or daytime sleepiness. The nurse intervenes to promote a cool, well-ventilated sleep environment, critical for optimizing rest. Poor sleep hygiene worsens narcolepsy, reducing treatment efficacy and increasing risks of sleep attacks or fatigue.
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