The nurse recognizes the client's death is impending when which assessment finding is noted?
1. Extremities appear mottled and cyanotic
2. Client requests a meeting with spiritual counselor
3. Heart rate and blood pressure increases
4. Increased appetite
1
Rationale 1: Mottling and cyanosis of the extremities are imminent signs of death.
Rationale 2: Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death.
Rationale 3: Heart rate and blood pressure are more likely to decrease than increase.
Rationale 4: Appetite is more likely to decrease than increase.
Global Rationale: Mottling and cyanosis of the extremities are imminent signs of death. Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase.
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