A nurse is assessing a client who is experiencing Cushing's triad due to increased intracranial pressure. Which of the following findings should the nurse expect?

A. Advise the family that a spiritual advisor will explain what life-sustaining measures are: While spiritual advisors can provide support, the nurse should focus on ensuring the client understands their rights and options rather than delegating decision-making explanations to family or advisors. The client’s autonomy is the priority.

B. Intervene if the client makes a health care decision the nurse does not agree with: The nurse must respect the client’s autonomy and decisions regarding their care, even if they personally disagree. Intervening based on personal beliefs violates ethical and legal principles of patient rights.

C. Ensure the client has identified a health care surrogate: Helping the client designate a health care surrogate ensures that someone is authorized to make decisions if the client becomes incapacitated. This is a critical step in advance care planning and aligns with legal and ethical standards.

D. Inform the client that once advance directives have been agreed upon, no changes can be implemented: Advance directives can be updated or revoked at any time while the client is competent. Providing inaccurate information could limit the client’s rights and autonomy, so the nurse should clarify that changes are always possible.

A. Offer high-calorie, high-protein snacks to the client: Providing nutrient-dense snacks helps address nutritional deficits caused by decreased appetite in depression. High-calorie, high-protein foods can improve energy levels, support overall health, and help prevent weight loss, which is a common concern in clients with depression.

B. Encourage the client to eat foods selected by the dietitian: While following a dietitian’s plan is beneficial, clients with depression and poor appetite may be resistant to structured meal plans. Offering flexible, appealing snacks is more practical and effective for ensuring adequate intake.

C. Weigh the client once each day: Daily weighing can be stressful or discouraging for clients with depression and may not directly improve nutritional intake. Weight monitoring is important but is secondary to actively supporting adequate nutrition through appealing foods.

D. Recommend the family provide the client privacy during meals: Privacy during meals may be helpful for some clients, but clients with depression often require encouragement, social support, and practical assistance to eat. Simply providing privacy may not address the underlying lack of appetite or insufficient nutrient intake.