The practical nurse (PN) is administering multiple medications to an older adult client. The client has been receiving all of the same medications for one week. Which assessment is most important for the PN to make?

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

A. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes: While it is important to acknowledge the client's feelings, immediately notifying the healthcare provider is not the first or most critical action. The client first needs a clear explanation of the purpose of the advance directive.
B. Ask a family member to describe the client's stated wishes regarding end-of-life care: Involving family members at this stage may undermine the client's autonomy. The focus should be on informing and empowering the client to make his own decisions.
C. Explain that the form identifies his personal health care wishes for any future event: It is important to clarify that advance directives are not just for those who are dying but help ensure that healthcare decisions align with the client’s wishes if he becomes unable to communicate in the future. Clear communication can ease misunderstandings and support informed decision-making.
D. Document his refusal in his electronic medical record using his exact words: While documentation is important, it should occur after ensuring that the client fully understands the purpose of the form. Providing education first supports client rights and informed consent.