A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?

Correct Answer: A

Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.

Correct Answer: C

Rationale: The correct action for the nurse to take first is to identify the client's typical bedtime routine. Understanding the client's sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.

Correct Answer: D

Rationale: When a client expresses feelings of hopelessness or worthlessness, it is crucial for the nurse to assess for suicidal ideation. Asking the client directly if she plans to harm herself is essential to determine the level of risk and ensure appropriate interventions are implemented. Recommending spiritual guidance (Choice A) may not address the immediate safety concerns related to suicidal ideation. Requesting additional support from the client's family (Choice B) is not as direct in addressing the client's safety. While stating that the client's response is a normal part of grief (Choice C) may provide validation, it does not address the potential risk of harm to the client.

Correct Answer: C

Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.

Correct Answer: A

Rationale: The correct action for the nurse to take is to remove the client's stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client's leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.