A nurse is caring for a client who is at the end of life. Which of the following interventions is most effective in reducing the client's social isolation?

Explanation:

A. "Delegate tasks such as vital signs regardless of the client's condition."

This statement is incorrect because delegation should be based on the complexity of the task, the client's condition and stability, the competence of the delegatee, and other factors. Vital signs are critical assessments that often require the direct involvement of a licensed nurse, especially when there are changes in the client's condition or if the client is unstable.

B. "Delegate simple tasks prior to evaluating the client's condition."

This statement is incorrect because delegation should not occur based solely on the simplicity of the task. Instead, the nurse should evaluate the client's condition first, assess the complexity of care required, and then delegate tasks accordingly. The client's needs, stability, and safety should guide the delegation process.

C. "Observe delegated tasks directly during task performance."

While direct observation of delegated tasks is important, it may not always be feasible or necessary for every task. Nurses should use their judgment to determine the level of supervision required based on factors such as the complexity of the task, the delegatee's experience and competence, and the client's condition. Direct observation may be necessary for more complex or critical tasks, but for routine and low-risk tasks, periodic checks and effective communication with the delegatee can suffice.

D. "Delegated tasks require follow-up to ensure compliance."

This statement is correct. Follow-up is essential to ensure that delegated tasks were performed correctly, safely, and in accordance with the client's care plan. It allows the nurse to verify task completion, assess the client's response if applicable, address any issues or concerns that arise, and provide feedback and guidance to the delegatee. Follow-up also helps maintain accountability and quality of care.

Explanation:

A. Increased bowel sounds:

In end-of-life care, clients often experience a decrease in bowel sounds rather than an increase. Bowel sounds may diminish or become absent as the body's systems slow down.

B. Hypertension:

Hypertension is less commonly observed in clients at the end of life. Instead, blood pressure may decrease as the body's overall function declines.

C. Mottled skin:

Mottled skin, characterized by a blotchy or marbled appearance, is a common finding in clients approaching the end of life. It occurs due to changes in peripheral circulation and may indicate decreased perfusion.

D. Moist mucous membranes:

In contrast to moist mucous membranes, clients at the end of life may experience dry mucous membranes. Reduced oral intake and hydration levels can lead to dryness of the mouth and mucous membranes.