A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

End-of-life care focuses on promoting comfort, dignity, and relief from distressing symptoms as a client approaches death. As physiological functions decline, clients often experience decreased oral intake, dry mucous membranes, reduced consciousness, and impaired ability to self-care. Nursing interventions prioritize comfort measures rather than curative treatments. Maintaining oral hygiene is especially important to prevent discomfort and maintain dignity in the dying process.

Rationale:
A. Providing oral care every 2 to 4 hours is essential in end-of-life care because decreased fluid intake and mouth breathing can cause significant dryness and discomfort. Regular oral hygiene helps prevent mucosal cracking, infection, and unpleasant odor, while improving overall comfort. This intervention directly supports dignity and symptom relief during the dying process.

B. Turning the client every 4 to 6 hours is not adequate for preventing skin breakdown in a terminally ill patient. Standard pressure injury prevention typically requires repositioning at least every 2 hours if tolerated. However, in end-of-life care, repositioning is individualized for comfort rather than strict schedules, and excessive movement may cause unnecessary distress.

C. Encouraging the client to eat foods high in protein is not appropriate during end-of-life care due to decreased appetite and metabolic changes associated with the dying process. Forcing or encouraging intake may cause discomfort, aspiration risk, and distress. Care at this stage focuses on comfort rather than nutritional optimization.

D. Keeping the head of the bed flat is inappropriate in end-of-life care because it can increase the risk of aspiration and respiratory discomfort. Elevating the head of the bed helps facilitate breathing and reduces secretion accumulation in the airway. Positioning should prioritize respiratory comfort and ease of breathing rather than supine positioning.

Client falls in healthcare settings require immediate post-fall assessment to identify potential injuries and ensure physiological stability. The nurse’s priority is to follow the ABCs and assess for life-threatening conditions before initiating documentation or reporting procedures. Vital signs provide essential information about hemodynamic status and possible internal injury or shock. Rapid assessment ensures early detection of complications such as head injury, fractures, or bleeding.

Rationale:
A. Measuring the client’s vital signs is the first priority because it helps determine immediate physiological stability following a fall. Changes in blood pressure, heart rate, respiratory rate, or oxygen saturation may indicate internal injury, pain response, or shock. This assessment guides urgency of further interventions and ensures patient safety before moving or documenting.

B. Documenting the fall in the client’s medical record is important but not the first action because immediate patient assessment takes priority. Documentation is completed after ensuring the client is stable and any injuries are identified and addressed. Accurate charting is essential for continuity of care but does not precede clinical evaluation.

C. Notifying the client’s provider is necessary after initial assessment but is not the first action. The nurse must first evaluate the client’s condition to provide accurate and relevant information to the provider. Immediate communication without assessment may delay critical interventions or provide incomplete clinical data.

D. Completing an incident report is required for institutional tracking and quality improvement but is not part of immediate patient care. It is done after the client has been assessed and stabilized. The report is a legal and administrative document and does not replace direct clinical evaluation or intervention.