A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!"

Exhibits

The client is resting in bed and cooperative with her mother at her bedside.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

Choice A rationale

While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.

Choice B rationale

Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.

Choice C rationale

Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.

Choice D rationale

Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.