A. Monitor the client's white blood cell count. An elevated white blood cell (WBC) count indicates infection and inflammation. Since MRSA is a bacterial infection, monitoring WBC levels helps assess the severity of the infection and response to treatment.

B. Send wound drainage for culture and sensitivity. A wound culture and sensitivity test confirm the presence of MRSA and determine the most effective antibiotic therapy. This is essential to ensure appropriate treatment and prevent antibiotic resistance.

C. Institute contact precautions for staff and visitors. MRSA is transmitted via direct contact, especially through wound drainage. Contact precautions include wearing gloves and gowns when handling the patient or contaminated materials to prevent the spread of infection.

D. Explain the purpose of a low bacteria diet. A low-bacteria diet (neutropenic diet) is used for immunocompromised patients, such as those undergoing chemotherapy, but it is not relevant for MRSA. The focus should be on infection control and wound care rather than dietary restrictions.

E. Use standard precautions and wear a mask. While standard precautions should always be followed, a mask is not necessary unless performing aerosol-generating procedures or if MRSA is present in the respiratory tract. In this case, contact precautions (gown and gloves) are the primary infection control measures.

The client's assessment findings of neuropathy and incontinence place him at a high risk for multiple other health issues and require immediate follow-up by the nurse.

Rationale:

Neuropathy. The client reports neuropathy in both hands and lower legs. Neuropathy leads to decreased sensation, increasing the risk of falls, pressure injuries, and unnoticed wounds, which can become severe due to diabetes-related poor healing. It also contributes to mobility limitations, further affecting the client’s safety and independence.

Incontinence. The client experiences urinary and fecal incontinence due to difficulty moving quickly enough to reach the bathroom. Incontinence increases the risk of skin breakdown, infections, and pressure ulcers, especially since the client has mobility issues and spends prolonged time sitting.

Moist skin. While moist skin may suggest sweating or autonomic dysfunction, it is not as significant a risk factor as neuropathy and incontinence, which directly impact skin integrity and mobility.

Coarse lung sounds. Coarse lung sounds may indicate fluid retention or respiratory congestion, but they are not as immediately concerning as neuropathy and incontinence, which increase the risk for skin damage, infection, and functional decline.

A. Immobility. The client requires a walker for mobility and reports difficulty repositioning in bed. Limited mobility increases the risk of pressure injuries due to prolonged pressure on certain areas, reducing blood flow and oxygen delivery to the skin.
B. Obesity. The client has a history of moderate obesity, which increases skin friction, moisture retention, and difficulty with self-care. Excess weight places additional pressure on bony prominences, elevating the risk of pressure ulcers.
C. Inadequate nutritional intake. The client has a poor appetite and decreased oral intake, which can lead to protein and nutrient deficiencies. Poor nutrition impairs skin integrity and delays wound healing, further increasing the risk of pressure injuries.
D. Incontinence. The client wears an incontinence brief due to occasional urinary and fecal accidents. Constant exposure to moisture from urine and stool can break down the skin barrier, making it more susceptible to infections and pressure injuries.
E. Decreased sensory perception. The client reports neuropathy in both hands and lower legs, reducing sensation. Impaired sensation can prevent the recognition of pressure, pain, or injury, leading to delayed intervention and increased risk of skin breakdown.
F. Coarse lung sounds. While coarse lung sounds may indicate respiratory congestion or infection, they do not directly contribute to skin injury risk. This factor is less relevant compared to others affecting skin integrity.
G. Diabetes mellitus. The client has poorly controlled type 1 diabetes, which impairs circulation and delays wound healing. Chronic hyperglycemia can lead to reduced immune response and increased susceptibility to infections and pressure ulcers.

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

A. Enzyme immunoassay. The enzyme immunoassay (EIA), also known as the ELISA test, is used as a primary screening test for HIV. If the EIA test is positive, a confirmatory test, such as the Western Blot, is performed to ensure accuracy.

B. Western Blot. The Western Blot is a confirmatory test for HIV used to verify positive results from an initial screening test. It detects specific HIV antibodies and is highly specific, reducing the likelihood of false positives.

C. White blood cell differential. A white blood cell (WBC) differential assesses the overall immune response but does not diagnose HIV. While some HIV patients may show low WBC counts, this test is not specific for HIV infection.

D. CD4+ cell count. CD4+ cell count is used to monitor disease progression and immune function in HIV-positive patients, but it is not a confirmatory test for diagnosing HIV. A low CD4+ count suggests HIV progression toward AIDS rather than initial diagnosis.

A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.

A. Accessibility to trauma care. In rural communities, access to trauma care is critical because emergency medical services (EMS) response times are often delayed due to long travel distances. Without nearby trauma centers, patients with life-threatening injuries, such as those from motor vehicle accidents or farm-related injuries, face higher mortality and morbidity rates. Ensuring rapid access to trauma care significantly improves survival outcomes.
B. Family planning center. While family planning services are important for reproductive health, they are not as immediately life-saving as access to trauma care in an emergency.
C. Annual health fair. Health fairs provide preventive education and screenings, which are beneficial but do not address immediate, life-threatening medical needs.
D. Weather-related disaster plan. While a disaster plan is important for emergency preparedness, trauma care is a more immediate and ongoing concern in rural settings, where high-risk injuries require timely medical intervention.

A. Thyroxine (T4). Congenital hypothyroidism is diagnosed by measuring low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). Infants with hypothyroidism have delayed metabolism, poor growth, and developmental delays. Reporting low T4 levels is critical for early treatment with levothyroxine to prevent intellectual disability and growth impairment.
B. Growth hormone (GH) levels. While GH is important for growth, it is not the primary diagnostic test for congenital hypothyroidism. GH deficiency is a separate endocrine disorder.
C. Follicle-stimulating hormone (FSH) levels. FSH is involved in reproductive development and is not relevant for diagnosing hypothyroidism in an infant.
D. Luteinizing hormone (LH) levels. LH plays a role in pubertal development and reproductive function, but it is not used to diagnose congenital hypothyroidism.

Potential Condition:
Diabetic neuropathy – The client has a history of type 1 diabetes, and her elevated Hemoglobin A1C (8.2%) suggests poor blood glucose control, which increases the risk of diabetic neuropathy.

Actions to Take:
Perform a sensory test on both feet – Diabetic neuropathy can cause loss of sensation in the feet. A sensory test helps assess nerve function and detect early signs of neuropathy.
Instruct the client to change to clean, dry socks – Proper foot care is crucial for preventing infections and complications in clients with diabetes. Keeping feet dry reduces the risk of skin breakdown and infections.

Parameters to Monitor:
Pedal pulses – Poor circulation is a common complication of diabetes and neuropathy. Monitoring pedal pulses helps assess blood flow to the feet.
Blood glucose – Tight glucose control is essential for preventing the progression of diabetic neuropathy. Monitoring blood glucose levels helps guide management and treatment adjustments.

A. Body mass index greater than 35 kg/m². A BMI of ≥35 kg/m² indicates severe obesity and significantly increases the risk of chronic diseases such as hypertension, diabetes, and cardiovascular disease. Clients with a BMI ≥35, especially with comorbidities, should be referred for obesity counseling, lifestyle modifications, and possibly medical or surgical interventions.
B. Daily caloric intake of 3,500 calories. While consuming 3,500 calories daily may contribute to weight gain, caloric intake alone is not the primary indicator for an obesity counseling referral. BMI provides a more standardized measure of obesity risk.
C. Client's expressed desire to lose 50 lb (22.7 kg). A client’s motivation is important, but referral criteria for obesity counseling are based on clinical indicators like BMI rather than weight loss goals alone.
D. Body weight 10% over ideal body weight. Being 10% over ideal body weight does not necessarily indicate obesity. Obesity is typically defined as a BMI ≥30 kg/m², so this alone would not automatically warrant an obesity counseling referral.