A patient with terminal illness expresses fear and anxiety about dying alone. What intervention should the palliative nurse prioritize to address the patient's concerns?
- A. Arrange for family members or loved ones to be present at the patient's bedside.
- B. Offer reassurance that dying alone is a common experience in palliative care.
- C. Recommend distracting activities to divert the patient's attention from their fears.
- D. Administer sedative medications to alleviate anxiety and promote relaxation.
Correct Answer: A
Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to arrange for family members or loved ones to be present at the patient's bedside. Having loved ones nearby can provide emotional support, comfort, and reassurance to the patient during their final moments. This can help alleviate the fear and anxiety the patient is experiencing about dying alone. Additionally, it can contribute to a sense of connectedness and peace for both the patient and their loved ones during this challenging time. Offering practical solutions to address the patient's emotional needs is key in providing holistic palliative care.
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A postpartum client presents with persistent, severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Notifying the healthcare provider immediately
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The presentation of persistent, severe headache, visual disturbances, and epigastric pain in a postpartum client could indicate the development of postpartum preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Prompt notification of the healthcare provider is essential to ensure timely assessment, diagnosis, and treatment to prevent potential complications for both the mother and baby. Encouraging rest, providing acetaminophen, or offering a massage are not appropriate interventions for addressing these symptoms, as they do not address the underlying cause and urgency of the situation.
Patient Hydee asks how she could Distinguish between true and false labor? Which is NOT included among the factors in which the nurse should base her answer from?
- A. Contractions
- B. Cervical by vaginal examination
- C. Vital signs
- D. Engagement of fetus
Correct Answer: D
Rationale: The engagement of the fetus refers to the baby's head moving down into the mother's pelvis in preparation for birth. This factor is not typically used to distinguish between true and false labor because it is a sign of progress in labor rather than a defining characteristic of true labor. In contrast, the factors that are commonly used to differentiate between true and false labor include contractions (e.g., regularity, intensity, duration), cervical changes observed through vaginal examination (e.g., effacement and dilation), and monitoring vital signs.
A patient presents with chest pain that occurs during heavy lifting or physical exertion and is relieved by rest. An electrocardiogram (ECG) may show transient ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Prinzmetal's angina
Correct Answer: A
Rationale: The patient's symptoms of chest pain occurring during heavy lifting or physical exertion and being relieved by rest are classic characteristics of stable angina. Stable angina is caused by transient myocardial ischemia due to a fixed coronary artery obstruction. Typically, the pain is predictable and reproducible, occurring with exertion and relieved by rest. The transient ST-segment depression on ECG is also a common finding in stable angina, reflecting myocardial ischemia during episodes of chest pain.
A patient presents with crushing chest pain that lasts longer than 20 minutes, diaphoresis, and dyspnea. An electrocardiogram (ECG) shows ST-segment elevation in the anterior leads. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Prinzmetal's angina
Correct Answer: C
Rationale: The patient is most likely experiencing an acute myocardial infarction (MI) based on the presentation of crushing chest pain lasting longer than 20 minutes, diaphoresis, dyspnea, and ST-segment elevation on the ECG. These symptoms are consistent with the classic presentation of an ST-segment elevation myocardial infarction (STEMI), which is a type of acute MI that is characterized by prolonged ischemia leading to myocardial cell death. In this case, the ST-segment elevation in the anterior leads indicates myocardial damage in the corresponding area of the heart supplied by the affected coronary artery. This is a medical emergency that requires urgent intervention to restore blood flow to the affected myocardium and prevent further complications.
Which among the members of the multidisciplinary team that the nurse BEST to collaborate with when the patient can benefit the use of leg prosthesis?
- A. Occupationa l therapist
- B. Podiatrist
- C. Physical therapist
- D. Pharmacist
Correct Answer: C
Rationale: A physical therapist would be the best member of the multidisciplinary team to collaborate with when a patient can benefit from using a leg prosthesis. Physical therapists specialize in assessing and treating movement disorders, including those related to amputation and prosthetic use. They can help the patient improve their mobility, strength, balance, and overall functional abilities with the prosthesis. Physical therapists can provide training on how to use the prosthesis effectively, reduce the risk of falls, and optimize the patient's independence and quality of life. Collaborating with a physical therapist ensures that the patient receives comprehensive care tailored to their specific needs and goals related to using a leg prosthesis.