Exhibits

Complete the following sentence by using the list of options.

Mrs. Thompson is at high risk for developing

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evidenced by the client's

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A. Review the client's current medication list and check for any missed doses. Evaluating medication adherence is important in managing chronic illnesses, as missed doses can lead to worsening symptoms. However, it is a secondary concern compared to assessing how the illness affects the client’s daily functioning and independence.
B. Assess the client's ability to perform activities of daily living (ADLs) and their impact on the client's overall health. Evaluating ADLs is a priority because it provides a comprehensive view of how the chronic illness affects the client's independence and quality of life. If the client struggles with ADLs, interventions may be needed to enhance their self-care, safety, and overall well-being.
C. Conduct a detailed family history to identify any genetic predispositions to the chronic illness. Understanding genetic predisposition is useful for long-term health planning but does not directly assess how well the client is currently managing their condition. The priority is to evaluate their present ability to function and manage daily tasks.
D. Focus on the client's most recent laboratory results and compare them to past results. Reviewing lab results helps monitor disease progression and treatment effectiveness, but it does not provide a full picture of the client's ability to manage their condition in daily life. Functional status is more immediately relevant to a home health assessment.

Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.

Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.

Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.

Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.

Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.

Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.

End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.