A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Click to highlight the data that indicate the client is in need of immediate health interventions.

The correct answer and explanation are:

A - Ask the client to describe what happened. Correct

This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.

B - Inform the charge nurse of the situation.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.

C - Complete a client adverse incident report.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.

D - Call the agency-based client advocate.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.

The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.

- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.

- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.

- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.

- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.

- Therefore, option A is the correct answer, while options B, C, and D are incorrect.

Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.

Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.

Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.