A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations
Based on these findings, the nurse recognizes which of the following?
A) These are signs of impending death.
B) These signs do not indicate any abnormality.
C) The client requires immediate resuscitation.
D) The client's family should be asked to leave.
Ans: A
The clinical signs of impending or approaching death include decreased blood pressure, urinary and/or bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations.
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