A nurse is caring for a client who has received a terminal diagnosis.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse identifies that the client is currently in Kübler-Ross's 

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stage of grief as evidenced by

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The most likely cause of the client’s condition based on the nurse’s observation is potential physical abuse and neglect by the caregiver.

Potential physical abuse and neglect by the caregiver. The presence of bruises in various stages of healing, malnutrition, poor hygiene, and fearful behavior suggests possible elder abuse and neglect. The caregiver’s agitation when questioned further raises suspicion. The nurse should follow facility protocols and report concerns to appropriate authorities for further investigation.

Medications that cause spontaneous bruising and skin changes in elderly individuals. While aspirin can increase the risk of bruising, it does not explain the signs of malnutrition, poor hygiene, and fearful behavior. These additional findings suggest a broader concern beyond medication side effects.

Poor dietary intake and lack of proper medical care due to the client's advanced age and disease. While dementia and heart disease can contribute to nutritional challenges, they do not account for unexplained bruising, fearfulness, or a caregiver’s defensive behavior. Malnutrition in this case is more likely due to neglect rather than disease progression.

Chronic illness leading to frailty and easy bruising. Chronic illnesses can make elderly individuals more vulnerable to bruising and weakness, but they do not explain poor hygiene, malnutrition, or the client's fearful demeanor, which are more indicative of abuse or neglect.

A. Requesting feedback from the patient's family about the patient's comfort. While family members can provide insight, they cannot reliably assess pain in an unconscious client. Pain assessment should be based on objective clinical observations rather than second-hand reports.
B. Monitoring changes in vital signs such as blood pressure and heart rate. While pain can cause changes in vital signs, this method is not the most reliable in end-of-life care. Vital signs may fluctuate due to the body’s natural decline rather than pain alone.
C. Assessing the patient's responsiveness to verbal stimuli. Responsiveness to verbal stimuli helps assess consciousness, but it does not directly determine pain levels. An unconscious client may still experience discomfort, requiring alternative assessment methods.
D. Observing for non-verbal cues such as facial expressions and body movements. In unconscious or non-verbal clients, pain is best assessed through behavioral cues like grimacing, restlessness, moaning, muscle tension, or changes in breathing patterns. These signs help determine whether pain interventions are effective or need adjustment.