A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

A. A family member is napping in the client's room.

This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.

B. A client refuses to eat at mealtime.

Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.

C. A client's bed alarm is malfunctioning.

This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.

D. An assistive personnel is late for the upcoming shift.

Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.

Choice A Reason:

"I'll listen to my favorite music to take my mind off the pain." This statement refers to distraction techniques, like listening to music, which can help manage pain but isn't specifically guided imagery.

Choice B Reason:

"I'll think about my grandfather's farm to reduce pain." This statement indicates an understanding of this technique. Guided imagery involves creating a detailed mental image or scenario that promotes relaxation and diminishes pain perception. In this case, the client visualizing a familiar, pleasant place like their grandfather's farm can be an effective form of guided imagery to alleviate pain by diverting attention and inducing relaxation.

Choice C Reason:

"I'll use focused breathing to control my pain." This statement does not indicate an understanding of this technique.

Focused breathing, while beneficial for relaxation and pain management, is a different technique from guided imagery.

Choice D Reason:

"I'll learn to notice the sensation of muscle tension." This statement refers to progressive muscle relaxation, a technique involving systematically tensing and relaxing muscle groups, which isn't guided imagery.