What action should the nurse take when a home hospice client exhibits Cheyne-Stokes breathing?
A) Tell the family that this type of breathing indicates improvement
B) Ask the family to leave the room
C) Prepare the family for imminent death
D) Begin postmortem care
C) Prepare the family for imminent death
Explanation: A) Cheyne-Stokes breathing is a sign of imminent death.
B) The family caring for a loved one should not be asked to leave the room at the time of death. Rather, they should be told that death is imminent.
C) Clinical manifestations of the active phase of dying include Cheyne-Stokes breathing, which is characterized by a waxing and waning of the depth of breathing with regularly recurring intervals of apnea. Cheyne-Stokes breathing is a sign of imminent death.
D) The client with Cheyne-Stokes breathing is in the final stages of dying. Postmortem care is given after the person has died.
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