Stress
Signs & Symptoms of Chronic Stress
headache, sleep problems, fuzzy thinking, lowered libido, increased susceptibility to cold, feelings of anxiety and frustration
What should the nurse prioritize for the family after their loved one has passed?
provide anticipatory guidance/support and acknowledge the feelings of the family
What is a priority for a hospice pt?
Providing comfort
What are proper precautions for a pt who has TB?
Have the pt in a room with negative pressure room
(causes pneumonitis and development of granulomas in lung tissue)
What should the pt's oxygen saturation be?
95% - 100%
How to Promote Sleep
Cluster care, create restful environment, promote comfort, support bedtime rituals
You have a pt with a NG tube. What is best practice to maintain care and maintenance if this pt is getting NG feedings?
Flush before and after feeds
What are examples of maladaptive coping strategies?
overeating, drinking alcohol excessively, smoking excess sleeping, or avoidance behavior
A 62-year-old pt has just been told he has a terminal illness. Which of the following statements supports a nursing diagnosis of spiritual distress related to diagnosis of terminal illness?
A. I have nothing to live for now
B. What will happen to my wife when I die?
C. How much longer do I have to live?
D. I need to go to church and pray for a miracle
A
A client in the ICU has just been pronounced deceased. The client's spouse is crying at the bedside. Which action by the nurse best demonstrates compassionate and therapeutic communication?
A. Tell the spouse, "You need to be strong right now for your family."
B. Sit quietly at the bedside and offer to stay with the spouse during this time
C. Immediately begin removing tubes and preparing the body for transport
D. Advise the spouse to step out so postmortem care can be performed
B.
What should you always do prior to entering a pt's room to prevent infection?
sanitize/wash hands
What are signs of hypoxia?
pallor or cyanosis, restlessness, apprehension, confusion, dizziness, fatigue, decreased LOC, tachycardia, tachypnea, and changes in BP
What is REM (rapid eye movement) essential for?
mental and emotional restoration
If a pt is on a clear liquid diet, what drink/food would be most appropriate?
A. pepsi
B. protein shake
C. apple juice
D. cereal with milk
C.
What are the 5 stages of Kubler Ross Stages of Grief?
Denial
Anger
Bargaining
Depression
Acceptance
What does postmortem care involve?
care of the pt's body after death, fulfilling any legal obligations (arranging transport to the morgue or funeral home), and determining the disposition of the pt's belongings
What is a normal grief response in a family member, after loss?
sadness
sense of emptiness, hopelessness, or detachment
If you are caring for a patient with pneumonia, what interventions might help this pt mobilize their secretions?
turning, coughing, deep breathing AND oxygen
What is pallor defined as?
paleness of skin
What are the 3 stages of the General Adaptation Syndrome (GAS)?
1. initial alarm stage
2. resistance
3. exhaustion OR recovery
What would be a therapeutic response to a spouse who just lost their husband/wife?
Reassure them it is not wrong to feel anger, relief, or other "unacceptable" feelings after the loss
Death is Imminent (signs)
more time spent sleeping, refuse most food, cessation of urination, hands and feet become cool and blue, rapid and shallow breathing
What would indicate that your pt's UTI has progressed (gotten worse)?
NEW onset confusion
Interventions appropriate for hospice care
comfort measures, providing family and caregiver support, respecting patient wishes
TB
What does an induration 15 mm or greater indicate?
considered positive in any person, including persons with no known risk factors for TB
A nurse is supervising a UAP who is providing care for a client in hospice with advanced heart failure. Which action by the UAP indicates a lack of understanding of compassionate end-of-life care?
A. the UAP says to the client "you'll need to keep drinking fluids, even if you're not thirsty, or you'll get dehydrated
B. the UAP gently repositions the client for comfort and places pillows for support
C. the UAP offers to provide oral care when the client is unable to perform it themselves
D. the UAP sits quietly with the client and reassures them they are not alone
A.