A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Choice A Reason:
The ammonia level of 55 mcg/dL falls within the normal range of 10 to 80 mcg/dL. Ammonia is a byproduct of protein metabolism and is converted to urea by the liver before being excreted by the kidneys. Elevated levels can indicate liver dysfunction, but in this case, the value does not warrant concern.

Choice B Reason:
A bilirubin level of 1.0 mg/dL is at the upper limit of the normal range, which is 0.3 to 1.0 mg/dL. Bilirubin is produced during the normal breakdown of red blood cells and is processed by the liver. While this value is at the higher end, it is not abnormal and does not require reporting to the provider unless there are symptoms of jaundice or other clinical signs of liver disease.

Choice C Reason:
The platelet count of 60,000/mm³ is significantly below the normal range of 150,000 to 450,000/mm³. Platelets are crucial for blood clotting, and a low count, known as thrombocytopenia, can increase the risk of bleeding, especially concerning in the context of an invasive procedure like a liver biopsy. This value should be reported to the provider as it may necessitate a change in the biopsy plan or require intervention to address the low platelet count.

Choice D Reason:
An AST level of 34 units/L is at the upper boundary of the normal range. AST is an enzyme found in high amounts in the liver, heart, and muscles, and it is released into the bloodstream when any of these tissues are damaged. While this value is at the upper limit, it is not elevated and typically would not need to be reported unless there are other indicators of liver injury or the patient is symptomatic.

Choice A Reason:
Keeping the blinds open may not be beneficial for a client experiencing sensory overload, especially if the outside environment is bright or busy. It could potentially exacerbate the sensory input that the client is receiving, which is counterproductive when trying to manage sensory overload.

Choice B Reason:
While playing quiet music might be soothing for some, it is not a universally applicable strategy for managing sensory overload. For a client with cardiomyopathy who is already experiencing sensory overload, adding additional sensory stimuli, even if it is meant to be calming, could be overwhelming.

Choice C Reason:
Placing the client near the nurses' station could result in increased noise and activity levels, which might contribute to sensory overload. The nurses' station is often a hub of activity and could provide constant stimulation that is not conducive to a client who needs a reduction in sensory input.

Choice D Reason:
Breaking up nursing care into small, frequent sessions can help manage sensory overload by reducing the amount of sensory input the client experiences at any one time. This approach allows the client to receive necessary care without overwhelming their senses, which is particularly important for individuals with cardiomyopathy who may be more susceptible to stress-induced complications.