The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.

A. These are indicative of inflammation within the vein, which is characteristic of phlebitis. Warmth is a common sign of inflammation, and the palpable cord suggests that the vein may be hardened or cord- like due to inflammation and irritation.
B. While this could indicate some form of vascular injury or extravasation, it is not a typical presentation of phlebitis. Phlebitis involves inflammation of the vein, which may cause redness, warmth, and tenderness along the course of the vein, but it typically does not manifest as a raised ecchymotic (bruised) area.
C. Swelling occurs due to inflammation within the vein, and tenderness is often present as a result of the irritation and inflammation. These symptoms are commonly observed in cases of phlebitis but are not specific.
D. These are not typical signs of phlebitis. Blanching (turning white) and coolness of the skin may suggest reduced blood flow to the area, which could occur in cases of ischemia or thrombosis but are not characteristic of phlebitis.