What action should the nurse take when a home hospice client exhibits Cheyne-Stokes breathing?
A) Tell the family that this type of breathing indicates improvement
B) Ask the family to leave the room
C) Prepare the family for imminent death
D) Begin postmortem care
C) Prepare the family for imminent death
Explanation: A) Cheyne-Stokes breathing is a sign of imminent death.
B) The family caring for a loved one should not be asked to leave the room at the time of death. Rather, they should be told that death is imminent.
C) Clinical manifestations of the active phase of dying include Cheyne-Stokes breathing, which is characterized by a waxing and waning of the depth of breathing with regularly recurring intervals of apnea. Cheyne-Stokes breathing is a sign of imminent death.
D) The client with Cheyne-Stokes breathing is in the final stages of dying. Postmortem care is given after the person has died.
You might also like to view...
The nurse auscultates the FHR and determines a rate of 112 bpm. Which action is appropriate?
1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen.
The nurse explains that as chronic glomerulonephritis develops, the kidney:
a. swells. b. atrophies. c. becomes increasingly scarred. d. produces copious urine.
Identify the proper method of administration of acetylcysteine (Mucosil) to decrease the possibility of irritation and bronchospasm.
A. Addition of a bronchodilator to the inhalation mixture will decrease irritation and bronchospasm. B. Addition of a leukotriene to the inhalation mixture will decrease irritation and bronchospasm. C. Addition of a bronchoconstrictor to the inhalation mixture will decrease irritation and bronchospasm. D. None of these are correct.
The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.)
a. Bread b. Cocoa c. Lettuce d. Spinach e. Chicken f. Instant coffee