A nurse is providing medication teaching to a client who has been prescribed warfarin. Which statement should the nurse include in the teaching?

A.While older adults are at risk for postoperative delirium, vertigo and orthostatic hypotension are specifically vestibular and hemodynamic issues rather than primary cognitive risk factors. Delirium is more closely linked to polypharmacy, anesthesia effects, and sleep deprivation. Although physiological stress contributes to confusion, these specific findings more directly jeopardize physical stability and safety during mobilization.

B.Malnutrition is an assessment finding related to chronic dietary intake, metabolic demands, or malabsorption syndromes rather than acute balance or blood pressure fluctuations. Vertigo may cause temporary nausea, but it does not serve as a primary predictor for postoperative nutritional failure. The nurse should focus on the immediate physical dangers posed by the client's inability to maintain an upright, stable posture.

C.Postoperative pain is an expected outcome of surgical trauma and is influenced by the type of procedure and individual pain thresholds. A history of vertigo or orthostatic hypotension does not increase the physiological intensity or perception of surgical pain. These conditions are cardiovascular and neurological in nature, primarily affecting the client's coordination and autonomic response to changes in position.

D.Vertigo causes a sensation of spinning and impaired balance, while orthostatic hypotension leads to a sudden drop in blood pressure upon standing, causing dizziness or syncope. In the postoperative period, where anesthesia and analgesics further impair coordination, these preexisting conditions significantly escalate the risk of accidental falls. The nurse must implement strict fall precautions to ensure the client's safety during early ambulation.

A.Restlessness and moaning are clinical indicators of terminal agitation or physical pain, both of which require immediate pharmacological or comfort intervention. Addressing suffering is the primary ethical and clinical goal of end-of-life care to ensure a peaceful transition. The nurse must prioritize these signs of distress over expected physiological changes that occur naturally during the active dying process in terminal cancer.

B.Cheyne-Stokes respirations are characterized by a rhythmic pattern of waxing and waning breathing depth followed by periods of apnea. This is a common and expected physiological sign of impending death as the brainstem becomes increasingly hypoxic and loses sensitivity to carbon dioxide. While significant to the family, it is not a sign of distress and does not require active medical intervention in hospice.

C.Loss of sphincter control leading to urinary and fecal incontinence is a natural result of generalized muscle relaxation and the shutting down of the nervous system during death. While this requires diligent skin care and hygiene to maintain the client's dignity and prevent breakdown, it is not an acute priority. The nurse should manage this with absorbent pads to keep the client dry and comfortable.

D.An irregular heart rhythm often occurs in the final stages of life as the cardiac conduction system fails and the heart becomes increasingly irritable. This expected hemodynamic decline is a part of the multisystem organ failure associated with terminal lung cancer and is not typically treated with antiarrhythmics in palliative care. The focus remains on comfort rather than the restoration of a normal sinus rhythm.