a nurse is caring for a patient who states, “I did not take my medication because my partner forgot to remind me.”. The nurse should identify that the patient is demonstrating which of the following defense mechanisms?

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

Choice A rationale
While adequate lighting is important for people with vision impairment, direct lighting from open window shades can create glare, which can make vision problems worse.
Choice B rationale
Facing the patient when speaking to them can help the patient use visual cues to better understand the conversation.
Choice C rationale
Using gestures can be helpful for some patients with vision impairment, but it may not be beneficial for a patient with moderate vision impairment who may not be able to see the gestures clearly.
Choice D rationale
Speaking loudly is not necessary for a patient with vision impairment unless they also have a hearing impairment.