Question : The nurse is caring for a terminally ill client who has 20-second periods : 2135499

1. The nurse is caring for a terminally ill client who has 20-second periods of pane followed by periods of deep and rapid breathing. Which of the following terms should the nurse use to document this finding?

a. Agonal breathing

b. Apneustic breathing

c. Death rattle respirations

d. Cheyne–Stokes respirations

2. The nurse is caring for a young adult who is dying after an automobile accident. The family members want to donate the client’s organs and ask the nurse how the decision when death has occurred is made. Which of the following is the basis for the nurses’ response to the family in this situation?

a. The client is flaccid and unresponsive.

b. The client is experiencing respiratory acidosis and is on a ventilator.

c. The client is unconscious with no brain stem activity.

d. Respiratory efforts cease and no apical pulse is audible.

3. The nurse is providing hospice care to a client who is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the following is the basis for the nurses’ response about these symptoms?

a. They will continue to increase until death finally occurs.

b. They are a normal response before these functions decrease.

c. They indicate a reflex response to the slowing of other body systems.

d. They may be associated with an improvement in the client’s condition.

4. The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a trip across the country “to settle some issues with my sisters and brothers.” Which of the responses should the nurse recognize that the client is manifesting?

a. Restlessness

b. Yearning and protest

c. Anxiety about unfinished business

d. Fear of the meaninglessness of one’s life

5. The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” Which of the following nursing diagnoses is appropriate?

a. Ineffective denial related to threat of unpleasant reality

b. Anxiety related to threat to current status

c. Caregiver role strain related to inexperience with caregiving

d. Hopelessness related to chronic stress