The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision?
1. Diarrhea
2. Muscle spasms
3. Slow, weak pulse
4. Decreased blood pressure
5. Cyanosis of the extremities
Correct Answer: 3, 4, 5
Rationale 1: Diarrhea is not a clinical manifestation of impending death.
Rationale 2: Muscle spasms are not a clinical manifestation of impending death.
Rationale 3: A slow, weak pulse is a clinical manifestation of impending death.
Rationale 4: Decreased blood pressure is a clinical manifestation of impending death.
Rationale 5: Cyanosis of the extremities is a clinical manifestation of impending death.
You might also like to view...
After teaching a client who is prescribed "voice rest" therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching?
a. "I will stay away from smokers to minimize inhalation of secondhand smoke." b. "When I speak, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least three quarts of water each day to stay hydrated."
You are the nurse creating the care plan for a patient newly admitted to your rehabilitation unit
The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patient's nursing care plan? A) Maintain joint mobility. B) Refer to social services. C) Ambulate three times every day. D) Perform passive range of motion twice daily.
Which strategy would promote time management for the nurse manager while interacting with a drop-in visitor?
1. Set office hours to eliminate drop-in visits. 2. Keep the office door closed. 3. Hold meetings in the nurse manager?s office. 4. Stand up to greet the visitor and remain standing.
When a nurse is working in an area of the hospital where the hair must be covered, such as the operating room, which item of protective equipment is donned first?
a. gloves c. cap b. gown d. mask