A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

A. Moist mucous membranes: Moist mucous membranes are typically a sign of good hydration and are not usually associated with end-of-life stages. In fact, patients nearing the end of life often experience dryness of the mouth and mucous membranes due to decreased fluid intake and certain medications. This dryness can lead to discomfort and difficulties in swallowing or speaking, which is why oral care is an important part of end-of-life care.

B. Irregular respirations: This is correct. As the body’s systems start to shut down in the final stages of life, irregular respirations, including periods of rapid breathing and pauses (Cheyne-Stokes respirations), can be a common symptom. This happens because the body can no longer effectively remove carbon dioxide, and the automatic process of breathing becomes less coordinated. This can be distressing to witness, but it’s usually not uncomfortable for the patient.

C. Tachycardia: While some patients may experience changes in heart rate, tachycardia is not typically a consistent finding in patients at the end of life. As the body weakens, the heart has to work harder to pump blood, which can sometimes lead to a faster heart rate. However, as the end of life approaches, the heart rate often slows down, and blood pressure decreases.

D. Hypertension: Hypertension, or high blood pressure, is not typically a symptom associated with end-of-life care. In the final stages of life, the body’s systems begin to slow down, and blood pressure often decreases. This is due to a combination of factors, including a slower heart rate and a decrease in the body’s ability to regulate blood pressure. It’s also worth noting that pain, anxiety, and certain medications can temporarily increase blood pressure, even in the end-of-life stages.

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial in addressing underlying issues, suspected abuse must be reported promptly to protect the client's safety. Referral for family therapy can be considered as part of a comprehensive intervention plan but should not delay reporting of suspected abuse.

B. Follow the agency's guidelines for reporting suspected abuse:

Reporting suspected abuse is the first priority when there are concerns about a client's safety. Following the agency's guidelines ensures that the appropriate authorities are notified and that the client receives the necessary protection and support.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises could put the client at further risk of harm. Suspected abuse requires immediate attention, and the nurse should follow established protocols for reporting and intervening in such situations.

D. Institute more frequent visits to the client's home:

While more frequent visits may allow for closer monitoring of the client's condition, suspected abuse should be addressed immediately through appropriate reporting channels. Increasing visit frequency alone may not adequately address the safety concerns and may delay necessary intervention.