A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death?
a. Redness of skin
b. Clear-colored urine
c. Tense muscles tone
d. Cheyne-Stokes breathing
ANS: D
Altered breathing such as Cheyne-Stokes pattern, apnea, labored, or irregular breathing is a sign of impending death. Cyanotic, pallor, or mottling of skin occurs. Urine is decreased and a dark color. Decreased muscle tone, relaxed jaw muscles, and sagging mouth also occur.
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