A nurse is caring for a patient who has impaired speech.
Which of the following actions should the nurse take?

Choice A rationale
Neurogenic bladder is a condition where a person lacks bladder control due to a brain, spinal cord or nerve condition. This is not the most fitting answer because the scenario does not provide information about any neurological conditions.
Choice B rationale
Urinary retention can lead to urinary tract infections. The retained urine provides a breeding ground for bacteria, which can lead to infection.
Choice C rationale
Bladder outlet obstruction is a condition where the bladder is not able to empty properly. While urinary retention could be a symptom of this condition, the scenario does not provide enough information to suggest this diagnosis.
Choice D rationale
Genitourinary System Effects is a broad term that refers to any effects on the genital and urinary systems. This is not the most fitting answer because it is less specific than Choice B2.

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.