The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
Report any change in urine color.
Keep mucous membranes moist.
Record the client’s daily weight.
Maintain in high Fowler’s position.
The Correct Answer is B
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.
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Correct Answer is A
Explanation
Choice A rationale
Beginning with questions that are less sensitive in nature helps build rapport and makes the client more comfortable. This approach gradually leads to more sensitive topics, reducing anxiety and promoting honest responses.
Choice B rationale
Getting the most difficult questions over with first can increase the client’s anxiety and discomfort, leading to less honest or incomplete answers. It is not an effective strategy for sensitive topics.
Choice C rationale
Sharing personal values to put the client at ease can introduce bias and affect the client’s responses. It is important to remain neutral and nonjudgmental.
Choice D rationale
Asking questions in a vague, non-specific format can lead to misunderstandings and incomplete information. Clear, direct questions are more effective for gathering accurate information.
Correct Answer is C
Explanation
Choice A rationale
Telling the parents that their child’s medical information is none of their business is not appropriate. It is important to communicate respectfully and explain the legal status of the emancipated minor.
Choice B rationale
Promising to give the results to the parents as soon as they are back from the laboratory is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.
Choice C rationale
Informing the parents that the nurse can only give medical information to their child because they are legally an adult is the best response. This explains the legal status of the emancipated minor and respects their autonomy.
Choice D rationale
Telling the parents that the healthcare provider will share the information with them is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.