NUR 130 Exam 4

The correct answer is B. Respite care.

Explanation:

Respite care is a service that provides temporary relief to primary caregivers, giving them a break from their caregiving responsibilities. This is particularly important in end-of-life care when the caregiver may experience physical, emotional, and mental fatigue. Respite care allows caregivers time to rest and recharge while ensuring that the client continues to receive the care they need. This service can be provided in a variety of settings, including at home, in a hospice facility, or at a dedicated respite care center.

Why the other options are incorrect:

A. Home care:

Home care refers to a range of health services that can be provided at home, including medical care, personal care, and assistance with daily activities. While home care can support the client, it does not specifically address the needs of the caregiver, which is the focus of the question. Home care is aimed more at meeting the client's needs rather than providing direct support to the caregiver.

C. Postmortem care:

Postmortem care refers to the care provided to the body after a person has passed away, including activities like preparing the body for viewing or transport. This service is focused on the deceased individual, not on supporting the caregiver. Therefore, it does not meet the need for caregiver support during the end-of-life process.

D. Restorative care:

Restorative care is focused on helping clients regain or maintain their independence and function after an illness or injury. While restorative care is important for improving a client’s quality of life, it does not directly provide support to the caregiver. It’s primarily centered around rehabilitation and recovery, not respite for the caregiver.

Summary:

Respite care is the most appropriate service for supporting a client’s caregiver, as it offers the caregiver temporary relief and a break from caregiving duties. This helps alleviate the stress and exhaustion that can accompany caring for someone at the end of life.

Correct Answer is B. Confront the APs to discuss their argument.

Explanation:

When a nurse overhears a disagreement between assistive personnel (APs), the appropriate action is to intervene and address the issue in a constructive manner. Confronting the APs to discuss their argument allows the nurse to mediate the situation, promote open communication, and resolve the conflict in a professional way. This demonstrates conflict resolution by encouraging the APs to express their concerns, identify the root cause of the disagreement, and work toward a mutually agreeable solution.

Why the Other Options are Incorrect:

A. Report the APs to the charge nurse: Reporting the APs immediately to the charge nurse without attempting to resolve the issue directly may escalate the situation unnecessarily. It is generally more effective to address the issue at the level where it occurs first before involving higher authorities unless the situation is serious or unresolved.

C. Allow the APs to resolve their issues: While it's important to foster independence among staff, leaving the APs to resolve their conflict on their own may not be effective, especially if the disagreement is affecting client care. Active mediation by the nurse helps guide the resolution process and ensures that the conflict doesn’t impact the quality of care provided to the client.

D. Tell the APs they are acting immature: Telling the APs they are acting immature is a judgmental and unprofessional way of addressing the conflict. It could escalate the tension and make the APs feel criticized, which may prevent productive resolution. A respectful and collaborative approach is needed for effective conflict resolution.

Summary:

The correct action is for the nurse to confront the APs and discuss their argument (B). This approach promotes open communication, allows the nurse to help mediate the conflict, and ensures the resolution is professional and focused on the well-being of the client.

Correct Answer is

A. A surgical procedure that was performed on the wrong site

B. An infant being discharged to the wrong family

D. A client who elopes from a healthcare facility

E. A stage 4 pressure injury that was acquired while in a healthcare facility

Explanation:

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Sentinel events signal the need for immediate investigation and response. The following are examples of sentinel events:

A. A surgical procedure that was performed on the wrong site: This is a classic example of a sentinel event. Performing surgery on the wrong site is a preventable error that can lead to serious harm or death and requires immediate attention and corrective actions.

B. An infant being discharged to the wrong family: This is also a sentinel event, as it involves a significant safety risk and can cause physical and emotional harm. It demands an urgent investigation and corrective measures to prevent recurrence.

D. A client who elopes from a healthcare facility: Elopement, especially in vulnerable clients (such as those with cognitive impairments or mental health conditions), is considered a sentinel event. It puts the client at serious risk and requires a prompt response to ensure patient safety.

E. A stage 4 pressure injury that was acquired while in a healthcare facility: Acquiring a stage 4 pressure injury in a healthcare setting, which could have been prevented with proper care and monitoring, is a sentinel event. It often indicates a failure in quality care and needs to be addressed immediately to prevent further harm.

Why the Other Option is Incorrect:

C. A client's partner displaying violent behavior: While this is concerning and needs to be addressed, it is not classified as a sentinel event unless it results in serious harm or injury to the client or others. The partner’s behavior might warrant a safety or security response, but it doesn’t meet the criteria for a sentinel event unless it escalates to significant harm.

Summary:

The correct answers are A, B, D, and E. These situations represent sentinel events because they involve unexpected occurrences that result in or have the potential to cause serious harm to patients, requiring immediate investigation and corrective action.

Correct answers:

A. Elevate the client's head of bed

C. Give the client mouth care every 2 hr

D. Increase the temperature in the client's room

E. Administer an opioid narcotic to the client

Explanation:

The client is in the active phase of dying, as indicated by decreased responsiveness, irregular breathing with rhonchi, mottling, and declining vital signs. The nurse’s role at this stage focuses on comfort care, not prolongation of life.

A. Elevate the client's head of bed:

Elevating the head promotes lung expansion, eases labored breathing, and helps drain secretions, improving the client's comfort.

C. Give the client mouth care every 2 hr:

Frequent oral care keeps the mouth moist and clean, reducing discomfort caused by dry mucous membranes, which is common in dying clients who can no longer eat or drink.

D. Increase the temperature in the client's room:

As peripheral circulation declines, extremities become cold. A warmer environment helps maintain comfort and reduces shivering or chill in the unconscious client.

E. Administer an opioid narcotic to the client:

Opioids are used to relieve pain and ease dyspnea, both of which the client is exhibiting (moaning, grimacing, tachypnea). This is an essential intervention in hospice care.

Why the incorrect option is wrong:

B. Insert a nasogastric tube for enteral feeding:

Not appropriate at end-of-life. Artificial feeding in dying clients often leads to increased secretions, aspiration risk, and discomfort, without improving quality of life.

Summary:

End-of-life care should prioritize non-invasive comfort measures such as positioning, oral hygiene, warmth, and effective pain management. Invasive procedures like tube feeding are contraindicated during the dying process.

Correct Answer is B. Uncomplicated grief.

Explanation:

Uncomplicated grief refers to the normal, natural response to loss, where the individual experiences sadness, mourning, and sorrow, but over time, the severity of the grief decreases as the person begins to adjust to life without the deceased. The client in this scenario reports that their grief is decreasing in severity and that they are looking forward to spending time with their grandchildren, indicating healthy progression through the grieving process. This aligns with uncomplicated grief, which involves feelings of sadness but does not impair a person's ability to resume normal functioning after a period of mourning.

Why the other options are incorrect:

A. Prolonged grief:

Prolonged grief, also known as persistent complex bereavement disorder, occurs when the grief does not lessen over time and continues to cause significant distress or impairment in the person’s ability to function. The client in this scenario is showing signs of improvement in their grief, making prolonged grief unlikely.

C. Anticipatory grief:

Anticipatory grief occurs before an actual loss, often in the context of a terminal illness or expected death. It involves grieving the loss before it occurs. In this case, the client is grieving after the loss of their partner, so anticipatory grief is not applicable.

D. Disenfranchised grief:

Disenfranchised grief refers to grief that is not openly acknowledged, socially supported, or validated. This may happen if the relationship is not recognized by society (e.g., a nontraditional relationship) or if the person is grieving in a way that is not accepted by others. The client in this scenario does not show signs of disenfranchised grief, as they are receiving support and their grief appears to be progressing normally.

Summary:

The client’s grief is progressing in a typical and healthy manner, decreasing in severity over time, and allowing them to look forward to activities, such as spending time with their grandchildren. This indicates uncomplicated grief, a normal response to loss. The other types of grief are characterized by more severe, prolonged, or unacknowledged emotional responses.

Correct Answer: D. Post-traumatic stress disorder (PTSD)

Explanation:

Post-traumatic stress disorder (PTSD) is a stress-related mental health condition that can develop following exposure to a traumatic event, such as violence, accidents, war, or natural disasters. A key diagnostic criterion for PTSD is that the symptoms—such as flashbacks, nightmares, hypervigilance, avoidance behaviors, and mood disturbances—persist for more than 1 month after the trauma. In this scenario, the client reports flashbacks related to an event that occurred a year ago, which fits the chronic and enduring pattern characteristic of PTSD. Flashbacks involve reliving the traumatic event, often with intense emotional or physical reactions, and are a hallmark feature of PTSD.

Why the Other Options Are Incorrect:

A. Episodic acute stress

Episodic acute stress refers to frequent episodes of short-term stress, often tied to specific life situations or personality traits, but it does not involve re-experiencing a traumatic event through flashbacks. It typically does not follow a traumatic event or persist over a year.

B. Acute stress disorder (ASD)

ASD involves symptoms similar to PTSD, such as dissociation, intrusive thoughts, and avoidance, but the key distinction is timing. ASD occurs within 3 days to 1 month after a traumatic event. Since the client is experiencing symptoms a year after the trauma, the diagnosis would be PTSD, not ASD.

C. Irritable bowel syndrome (IBS)

IBS is a gastrointestinal disorder characterized by abdominal pain, bloating, and altered bowel habits, and while it can be exacerbated by stress, it does not involve psychological flashbacks or trauma-related symptoms. This choice is unrelated to the mental health symptoms described.

Summary:

The correct answer is D. Post-traumatic stress disorder (PTSD), as the client is experiencing flashbacks related to a traumatic event that occurred more than a year ago, which is consistent with the diagnosis of PTSD. The other options either do not involve trauma or do not match the chronic nature of the symptoms.

Correct Answer is C. Situational.

Explanation:

Situational stressors refer to stress caused by specific, often unexpected, events or circumstances in a person's life. In this case, the client is reporting work-related stress, which is linked to a specific situation or environment — their work setting. This type of stress arises from changes or challenges within a particular context, such as conflicts with coworkers, high demands, or organizational changes. These types of stressors are typically temporary and can be managed or resolved with appropriate coping strategies or changes in the environment.

Why the Other Options are Incorrect:

A. Developmental:

Developmental stressors are related to specific life stages or milestones, such as adolescence, parenthood, or aging. These stressors are expected and arise as a person moves through different phases of life. Work-related stress does not fit this category, as it is not tied to a specific developmental stage.

B. Cultural:

Cultural stressors are those that stem from cultural differences, expectations, or conflicts. These stressors arise when there are misunderstandings or pressures related to cultural norms, values, or practices. While work-related stress can intersect with cultural issues, in this case, it is the nature of the work itself that is the source of stress, not a cultural factor.

D. Adventitious:

Adventitious stressors are rare and unpredictable events that occur in life, such as natural disasters, accidents, or major crises. These stressors are typically external and overwhelming. While work stress can be challenging, it is not considered an adventitious stressor because it is more commonly part of everyday life rather than an unexpected or catastrophic event.

Summary:

The correct answer is C. Situational. Work-related stress is a type of stress that arises from specific situations or circumstances, which can be resolved or managed by addressing the work environment or stressors involved.

Correct Answer is:

B. Financial concerns

C. Cultural practices

D. Religious beliefs

E. Gender

Explanation:

Several factors influence a client’s perception of death, including financial concerns, cultural practices, religious beliefs, and gender. Each of these factors plays a significant role in how a person understands and copes with death and the dying process.

B. Financial concerns:

Financial concerns can influence how individuals approach death, especially in terms of end-of-life care and funeral arrangements. The financial strain of medical bills, insurance, and funeral costs can impact the overall experience and perception of death, as these practical issues can add stress and affect emotional well-being.

C. Cultural practices:

Cultural practices are crucial in shaping how individuals perceive and experience death. Different cultures have distinct rituals, beliefs, and mourning practices, which affect the individual’s response to death. Cultural norms may dictate how grief is expressed, how death is understood, and what happens after death, influencing one’s emotional response.

D. Religious beliefs:

Religious beliefs often offer a framework for understanding the afterlife, the purpose of life, and the significance of death. These beliefs strongly shape how a person perceives death, influences their coping mechanisms, and can provide comfort and meaning during the grieving process.

E. Gender:

Gender influences how individuals express grief and cope with loss, as societal norms often shape emotional expression. Men and women might experience and demonstrate grief differently due to cultural expectations of their roles and emotional responses, which can affect their perceptions of death.

Why the Other Option is Incorrect:

A. Education level:

While education may affect an individual’s general understanding of death, it does not directly influence their emotional or cultural perception of death. Education might provide more information about death, but it is not as critical a factor as financial concerns, cultural practices, religious beliefs, or gender when it comes to the perception of death.

Summary:

The perception of death is strongly influenced by financial concerns, cultural practices, religious beliefs, and gender. While education provides knowledge, it is not a primary factor in shaping emotional or cultural responses to death.

Correct Answer: A. Physical therapist

Explanation:

A physical therapist (PT) is a healthcare professional who focuses on improving a client’s mobility, strength, balance, and coordination—especially after events like a stroke, which can cause hemiparesis (weakness on one side of the body). In this scenario, because the client requires assistance with strengthening the affected side, a referral to a physical therapist is appropriate. The PT will design a personalized rehabilitation plan to restore function, prevent complications (like muscle atrophy or joint contractures), and enhance the client’s independence.

Why the Other Options Are Incorrect:

B. Respiratory therapist

A respiratory therapist helps manage breathing issues and provides care such as oxygen therapy, ventilator support, and pulmonary hygiene. They are not involved in muscular strengthening or mobility rehabilitation.

C. Social worker

Social workers assist clients with psychosocial needs, discharge planning, counseling, and access to community resources. While important to the overall care team, they do not address physical strengthening.

D. Occupational therapist

Occupational therapists (OTs) assist clients in relearning activities of daily living (ADLs), such as dressing, bathing, and eating. While they may also help with functional use of the affected limb, their focus is not primarily on muscle strengthening or large motor function—that falls under the PT’s domain.

Summary:

The correct answer is A. Physical therapist, as this professional focuses on strengthening and mobility, which are critical needs for a client recovering from a stroke and experiencing physical weakness on one side.