A nurse is assessing a client whose parent has coronary artery disease (CAD). What should the nurse plan to incorporate into the client's care plan?

A. Ask the client to describe the wound care steps to evaluate teaching effectiveness: Evaluating the client’s understanding is the next step after education. Asking the client to verbalize or demonstrate the steps ensures they have correctly learned the procedure and allows the nurse to clarify any misconceptions.

B. Set goals that the client will be able to perform wound care independently: Goal-setting occurs during the planning phase of the nursing process. While important, it should be established before or during teaching rather than immediately after instruction.

C. Assess the wound for complications and document the findings in the client's chart: Wound assessment is an ongoing clinical responsibility but does not directly evaluate the effectiveness of the client’s learning or teaching provided.

D. Document in the electronic health record the client's risk for deficient knowledge: Documentation of teaching and learning outcomes is essential, but it should follow the evaluation of the client’s understanding to reflect accurate progress and identify remaining educational needs.

A. A client who is reporting a severe headache and new vision changes: Sudden severe headache with vision changes may indicate a potentially life-threatening condition such as a stroke, aneurysm, or increased intracranial pressure. This client requires an immediate emergency assessment to prevent serious complications.

B. A client who requires assistance when transferring to the exam table: Needing help with transfers is important for safety but does not indicate an urgent medical condition. This task can be addressed after more critical clients are assessed.

C. A client who requires a follow-up physical for their medication refill: Routine follow-up for prescription refills is non-urgent and can safely be scheduled after emergency or acute cases are addressed.

D. A client who is reporting minor swelling and pain in their left foot: Minor swelling and pain are usually non-life-threatening. While assessment is necessary, it does not require immediate emergency evaluation compared to acute neurological or vision changes.