A client nearing the end of life requests that he be given no food or fluids.
The physician orders the insertion of a nasogastric tube to feed the client.
What situation does this create for the nurse providing care?

Choice A rationale

Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.

Choice B rationale

Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.

Choice C rationale

Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.

Choice D rationale

Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.

Choice A rationale

An older adult client without family support who is uncertain about a significant life change like moving to assisted living is particularly vulnerable. The nurse advocate can help this client understand their options, express their concerns, and ensure their wishes are considered, as they may lack the resources or confidence to navigate this process independently, making advocacy crucial for their well-being and autonomy.

Choice B rationale

A client who makes an informed decision to refuse chemotherapy is exercising their autonomy. While the nurse supports this decision, the client is already empowered and making their own choices based on understanding, thus requiring less direct advocacy in the sense of ensuring their voice is heard or their rights are upheld against potential opposition.

Choice C rationale

A client undergoing a repeat procedure is likely familiar with the process and has presumably consented previously. While the nurse ensures they are still informed and comfortable, the need for strong advocacy to ensure their wishes are respected against external pressures is less pronounced compared to a vulnerable client facing a new and uncertain situation.

Choice D rationale

A client who chooses alternative treatments after being educated on conventional options is also exercising their autonomy based on their values and understanding. The nurse's role is to ensure this decision is informed, but the client is already acting as their own advocate by making a conscious choice, reducing the immediate need for external advocacy.