A nurse is caring for a client who has terminal cancer and is receiving hospice care. Exhibits Click to highlight the information from the nurse's notes that indicate the client is actively dying. 2000: Temperature 35.3° C (95.5°F) Heart rate 42/min Blood pressure 62/ min Hg palpated Called by family requesting visit to client. Client does not arouse to verbal, tactile, or painful stimulation. Cheyne-stokes breathing noisy respirations. Bowel sounds 4 quadrants. Family reports no urine output in last 4 hr. Skin intact. Family gathered around client. Update on client's condition provided.

Rationale for Correct Findings: Temperature 35.3° C (95.5°F): A drop in body temperature is common in the final hours as the body loses its ability to regulate temperature. This change often indicates reduced circulation and metabolism due to impending death. Heart rate 42/min: Bradycardia suggests reduced cardiac output and diminished perfusion, common in end-of-life stages. This slowing of the heart is often a precursor to cessation of cardiac activity. Blood pressure 62/— mm Hg palpated: A non-measurable diastolic pressure with only palpable systolic pressure signals profound hypotension. This is consistent with the circulatory collapse observed in actively dying patients. Client does not arouse to verbal, tactile, or painful stimulation: Unresponsiveness to all forms of stimuli is a key sign of active dying and declining neurological function. This change often occurs shortly before death. Cheyne-Stokes breathing, noisy respirations: This irregular breathing pattern with periods of apnea and deep breaths signals neurological decline. Noisy respirations, often called the "death rattle," result from loss of airway clearance ability. Family reports no urine output in last 4 hr: Oliguria progressing to anuria reflects kidney shutdown, a critical sign of multi-organ failure. This is a frequent finding in the final phase of life. Rationale for Incorrect Findings: Skin intact: Intact skin indicates preserved skin integrity and absence of pressure injury or breakdown. While reassuring for comfort, this finding does not indicate death is imminent. Bowel sounds in all four quadrants: Presence of bowel sounds suggests that some gastrointestinal activity remains. Bowel sounds alone are not reliable indicators of whether a client is actively dying and can persist late into the dying process.