ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 10 : End-of-Life Care Questions
Question 1 of 5
The nurse is caring for a client who is dying in a hospice setting. The family is unsure whether to go home for rest or spend the night with the client. Which body system would the nurse assess to provide the first data on decline?
Correct Answer: B
Rationale: The key word is 'first'. Failing of cardiac functioning is one of the first signs that a condition is worsening. Symptoms within the other systems can also denote deterioration over time.
Question 2 of 5
A nurse is caring for a client whose death is imminent. The family asks the nurse why there is a rattling in their loved one's chest. What information about this process should the nurse convey?
Correct Answer: C
Rationale: Failure of the heart's pumping function causes fluid to collect in the pulmonary circulation. Also, there is an accumulation of secretions in the respiratory tract. Both account for noisy respirations or what is called the 'death rattle.' The client's impaired peripheral circulation causes pallor and cold extremities, not fluid accumulation in the lungs. Decreased perfusion to the kidneys causes urine volume to diminish and toxic waste products to accumulate. It does not cause fluid accumulation in the lungs. Aspiration of oral fluids can occur if the client is able to take fluids. However, a client whose death is imminent is not taking oral fluids.
Question 3 of 5
As the moment of death approaches, which of the following does the nurse encourage the family to do?
Correct Answer: C
Rationale: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.
Question 4 of 5
The family of a client who is dying and being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite?
Correct Answer: D
Rationale: Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them.
Question 5 of 5
The nurse is caring for a client who is in the dying process. The nurse is reviewing prescriptions to confirm that all is being done to meet client needs. Which additional nursing intervention may be helpful?
Correct Answer: C
Rationale: A drop in blood pressure and heart failure lead to poor tissue and organ perfusion. Repositioning the client every 2 hours protects the skin from breakdown. Typically, the client is at a semi-Fowler's position to assist with respiratory function. Glycerin products pull moisture from the tissue and accentuate the drying process. Extra covers are typically needed to ensure comfort.