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An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

 

 

The correct answer is A. Flushed, peeling skin

Choice A reason: Flushed, peeling skin is a classic sign of scarlet fever, which is a condition that can arise from Streptococcal pharyngitis. Scarlet fever is characterized by a red rash that can cover most of the body and may lead to the skin peeling. This symptom is a direct reaction to the toxins produced by the Streptococcal bacteria.

Choice B reason: Red bumps across the chest could be indicative of many conditions and are not specifically characteristic of the reaction to toxins produced by Streptococcal bacteria. While a rash is common in scarlet fever, it typically starts on the face or neck and spreads to the rest of the body, rather than presenting as isolated red bumps.

Choice C reason: A white coating on the tongue, often referred to as “strawberry tongue,” is indeed associated with scarlet fever. However, it is not the clearest indication of a reaction to the toxins. The white coating usually precedes the strawberry-like appearance, where the tongue becomes red and bumpy.

Choice D reason: While a high fever is a symptom of scarlet fever, it is not specific to the reaction to toxins from Streptococcal bacteria, as many infections can cause high fevers. The term “protracted” suggests a prolonged fever, which could be seen in various conditions.

Choice A: Obtain a blood pressure reading before the client gets out of bed. This is the most important intervention, as it can prevent or detect orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing. Orthostatic hypotension can cause dizziness, fainting, or falls, and it can be caused by medications, dehydration, or cardiac problems.

Choice B: Monitor and record the client's urinary output every day. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The urinary output should be monitored for signs of fluid balance, kidney function, or infection, but it is not a priority for this client.

Choice C: Provide the client with teaching regarding a cardiac diet. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The cardiac diet should be taught to promote heart health, lower cholesterol, and reduce sodium intake, but it is not a priority for this client.

Choice D: Assess the client's vital signs every 4 hours when awake. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The vital signs should be assessed for signs of infection, pain, or hemodynamic instability, but they are not a priority for this client.