A terminally ill patient who is not able to talk is demonstrating restlessness. What actions can the nurse take to help this patient achieve comfort? (Select all that apply.)
a. Medicate for pain.
b. Elevate the head of the bed.
c. Measure oxygen saturation.
d. Reposition the patient in bed.
e. Ensure incontinence pad is clean and dry.
ANS: A, C, D, E
For the terminally ill patient who is unable to verbally communicate needs but is demonstrating restlessness the nurse can medicate for pain, measure oxygen saturation, reposition the patient in bed, and ensure that an incontinence pad is clean and dry. B. Elevating the head of the bed may increase discomfort and is used for the patient who is experiencing dyspnea or other respiratory difficulty.
You might also like to view...
Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia (select all that apply):
A. Monitors the patient's vital signs before and after the procedure. B. Medicate prior to procedure if ordered. C. Educate patient and patient's family. D. Consent is not required. E. The patient may be slightly confused after the procedure.
Sarah, who is 2 years old, is having frequent temper tantrums. Her parents are concerned that she is having "mental" problems. The best response is to tell the parents that her behav-ior is
1. definitely abnormal. 2. common for her age group. 3. due to inadequate parenting. 4. a product of sibling jealousy.
A patient, age 54, is on postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia
In planning for her care, the nurse suspects the patient may have a. bacterial pneumonia. b. aspiration pneumonia. c. viral pneumonia. d. atypical pneumonia.
A newly admitted patient is withdrawn and does not seek out interaction with staff or patients. Nursing interventions should focus on which element of the treatment environment?
a. Norms b. Safety c. Structure d. Limit-setting