A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

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Question 1 of 5

A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

Correct Answer: C

Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention. A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario. B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications. D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.

Question 2 of 5

A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country to settle some issues with their siblings. The nurse recognizes that the patient is manifesting which psychosocial response to death?

Correct Answer: C

Rationale: The correct answer is C: Anxiety about unfinished business. The patient's desire to settle issues with their siblings before death indicates a concern about unresolved matters. This response aligns with the concept of psychosocial responses to death, specifically the need for closure and resolution. Restlessness (choice A) may not necessarily indicate a specific focus on unfinished business. Yearning and protest (choice B) typically refer to the initial stages of grief, not specifically related to settling unresolved issues. Fear of the meaninglessness of one's life (choice D) is more existential and philosophical, whereas the patient's focus here is on addressing specific issues with their siblings.

Question 3 of 5

A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?

Correct Answer: B

Rationale: The correct answer is B: Cry along with the patient’s family members. This action demonstrates empathy and support for the family's grief, showing that the nurse acknowledges and shares their feelings. It can help the family feel understood and supported during a difficult time. By crying with the family, the nurse can validate their emotions and provide comfort without intruding on their personal space. This approach fosters a sense of connection and trust between the nurse and the family, enhancing the quality of care provided. Incorrect Choices: A: Contact a grief counselor as soon as possible - This choice may be premature and could come across as impersonal or distancing in the immediate aftermath of the patient’s death. C: Leave the home as soon as possible - This choice would be insensitive and could make the family feel abandoned in their time of need. D: Consider whether working in hospice is desirable because patient losses are common - This choice is inappropriate as it suggests the nurse should reconsider their career choice based on emotional reactions,

Question 4 of 5

Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

Correct Answer: A

Rationale: The correct answer is A because providing postmortem care to a dying patient is a task that can be safely delegated to an LPN/LVN. This includes tasks such as preparing the body, cleaning, and positioning after death. LPNs/LVNs are trained and competent in performing these duties under the supervision of a registered nurse or physician. Choices B, C, and D are incorrect because they involve critical thinking, assessment, and teaching skills that are typically within the scope of practice of a registered nurse. Encouraging family members to talk with the patient, determining assessment frequency, and educating about signs of approaching death require a higher level of nursing judgment and expertise, which is beyond the scope of an LPN/LVN's role.

Question 5 of 5

A family member tells the nurse, 'I don’t know how I’m going to manage without my mother. She took care of everything for us.' Which response by the nurse is most appropriate?

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the family member's feelings while offering support and resources for managing the situation gradually. By providing resources, the nurse empowers the family member to learn how to handle things independently over time. This approach promotes self-reliance and resilience. Choice B focuses on time rather than active coping strategies, which may not address the family member's immediate needs. Choice C suggests shifting responsibilities to another family member without considering the emotional impact. Choice D jumps to the conclusion of needing professional counseling without exploring other potential solutions or support systems.

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