A home care nurse is completing a comprehensive assessment & sees that the client has written "spiritual but no specific religious denomination". How should the nurse interpret this data? The client...

This statement raises concern because it suggests that the client is experiencing thoughts of hopelessness and suicidal ideation. Expressions of feeling overwhelmed by pain to the extent of questioning the desire to continue living indicate a need for immediate attention and intervention to address the client's emotional distress and ensure their safety.

B. This statement indicates the client's proactive approach to pain management by taking medication preemptively before pain becomes severe. It reflects an understanding of pain management strategies and a willingness to address pain effectively.

C. Although this statement acknowledges the challenge of coping with pain, it also suggests the client's attempts to cope by mentally dissociating from the pain. While coping mechanisms vary among individuals, this response does not raise immediate concern unless accompanied by more severe signs of distress.

D. This statement acknowledges the chronic nature of the client's pain and its impact on daily activities but does not indicate thoughts of self-harm or severe emotional distress. It reflects the client's adaptation to living with pain and a willingness to engage in activities despite its presence.

A. Temperature: While temperature assessment is important in evaluating a client's condition, it primarily indicates the presence of fever, which the client already reports. However, it does not provide direct information about the client's fluid status.

B. BP and pulse in lying, then sitting and standing positions: Assessing blood pressure (BP) and pulse in different positions (lying, sitting, and standing) helps evaluate orthostatic changes, which can indicate volume depletion or dehydration. A drop in BP and an increase in pulse rate upon standing suggest volume depletion and orthostatic hypotension, which are indicators of fluid loss.

C. Pulse oximetry reading on room air: Pulse oximetry measures the oxygen saturation of arterial blood and is primarily used to assess respiratory status and oxygenation. While it provides valuable information about oxygen levels, it does not directly assess fluid status.

D. Respiratory rate and depth: Respiratory rate and depth can be affected by various factors, including pain, fever, and respiratory conditions. While changes in respiratory rate and depth can indicate distress or respiratory compromise, they are not specific indicators of fluid status and may not directly reflect hydration status.