The nurse is caring for a patient who is unconscious.
Which action by the nurse is appropriate?

Choice A rationale

Discouraging the family from talking about death can hinder their grieving process and may prevent the dying client from having important conversations and finding closure. Open communication about death and dying is often therapeutic for both the client and their family members, allowing them to express emotions and support each other.

Choice B rationale

Informing the family that the client may soon be out of danger when the client is actively dying of renal failure is providing false reassurance and can erode trust between the nurse and the family. It is crucial to be honest and compassionate about the client's prognosis, preparing the family for the impending death rather than offering false hope.

Choice C rationale

While rest is important for a dying client, encouraging the family to leave the client alone may deprive both the client and the family of valuable time for connection and saying goodbye. The presence and support of loved ones can provide comfort to the dying person and begin the grieving process for the family.

Choice D rationale

Informing the family that it is time to bid farewell acknowledges the reality of the situation and provides an opportunity for the family to express their love, say their goodbyes, and find closure. This supportive action respects the dying process and the emotional needs of the family members as they face the imminent loss of their loved one. .

Choice A rationale

Fluid Volume Excess occurs in congestive heart failure due to the heart's inability to pump blood effectively, leading to increased hydrostatic pressure in the capillaries. This pressure forces fluid into the interstitial spaces, causing edema. Orthopnea, or difficulty breathing while lying flat, results from the redistribution of this excess fluid into the pulmonary circulation when supine, increasing pressure in the lungs.

Choice B rationale

Fluid Volume Deficit is characterized by dehydration, typically presenting with symptoms like poor skin turgor, dry mucous membranes, and concentrated urine. Confusion in dehydration is due to reduced cerebral perfusion. These signs and symptoms are contrary to the findings of edema and orthopnea, which indicate fluid overload, not deficit.

Choice C rationale

Impaired Gas Exchange is a potential complication of congestive heart failure due to fluid accumulation in the lungs (pulmonary edema). While orthopnea is a symptom of this, the primary evidence for impaired gas exchange would be abnormal blood gas values (e.g., low PaO2, high PaCO2) and clinical signs of hypoxemia, not just orthopnea and shortness of breath alone.

Choice D rationale

Risk for Falls is a relevant concern for an elderly client with confusion, as altered mental status can impair judgment and coordination, increasing the likelihood of falls. However, this diagnosis does not directly address the primary physiological problem of fluid overload evidenced by edema and orthopnea in the context of heart failure.