A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

Dependent personality disorder is characterized by an excessive reliance on others for decision-making and a fear of being alone or taking responsibility. Encouraging the client to be assertive helps promote their independence and self-confidence. It allows them to express their needs and preferences, make decisions, and take responsibility for their own actions. Empowering the client to be assertive can enhance their overall well-being and promote healthier relationships.

Limiting the client's social interactions may exacerbate their dependency and hinder their progress in developing more self-reliance and independent coping skills. It is important to encourage appropriate and healthy social interactions while also promoting the client's independence.

Maintaining a verbal no-harm contract with the client is a strategy more commonly used for clients at risk of self-harm or harm to others. It may not be directly applicable to the care of a client with dependent personality disorder unless there are specific safety concerns. Assuming responsibility for making the client's decisions would reinforce their dependency and enable their avoidance of taking personal responsibility. It is important to promote autonomy and support the client in making their own decisions whenever possible.

A.a. Heart rate (98/min): A heart rate of 98/min is within the normal range for adults (60-100 bpm). This does not indicate an immediate need for further evaluation based on the provided data.

B.Blood pressure (112/88 mmHg): The blood pressure reading is within normal limits. This does not suggest an immediate concern.

C. Temperature: The client reports a low-grade fever (38.1°C or 100.5°F), which suggests an ongoing infection or inflammatory process. Further evaluation is necessary.

D.Respiratory complaint: A productive cough with blood-tinged sputum, especially in combination with symptoms such as fatigue, night sweats, and weight loss, is concerning and warrants further evaluation for possible serious conditions such as tuberculosis (TB) or other respiratory infections.

e.Oxygen saturation (98% on room air):The oxygen saturation is normal. This finding does not indicate an immediate need for further evaluation.

F.Weight loss: The client reports a significant weight loss of 26 kg (5 lbs) over the past week. Unintentional weight loss can be a concerning symptom and may indicate an underlying medical condition that requires further investigation.

G.Sputum characteristics: Blood-tinged sputum, especially with other symptoms like cough, fever, and night sweats, can be indicative of serious conditions such as TB or other respiratory infections and needs further evaluation.

H.Travel history: Recent travel to a region where certain infectious diseases are prevalent (such as TB) is a critical factor that requires further evaluation in the context of the client's symptoms.