A nurse is assisting with the care of a client.

Exhibits

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A. Case manager. A case manager assists clients in accessing community resources, including financial assistance programs such as WIC (Women, Infants, and Children) and other social services that provide formula for infants. This referral ensures the client receives the necessary support to meet her baby's nutritional needs.
B. Primary care provider. A primary care provider focuses on the client’s medical care rather than financial or social concerns. While they may provide guidance on infant nutrition, they are not the best resource for addressing the client’s financial difficulties in obtaining formula.
C. Nutritionist. A nutritionist provides dietary guidance but does not handle financial assistance programs. They may educate the client on proper infant feeding, but they cannot directly assist with obtaining formula for a client who cannot afford it.
D. Pediatric nurse practitioner. A pediatric nurse practitioner specializes in infant health but does not typically manage financial concerns. They may assess the baby’s growth and nutritional needs but would refer the client to a case manager or social services for formula assistance.

A. Completing an incident report is required for tracking falls and improving safety measures, but it is not the first priority. The nurse must first assess the client to determine if immediate medical intervention is needed. Delay in assessment could lead to unrecognized injuries or complications. Incident reports are also not part of the medical record and should be completed after client care. Ensuring client stability always takes precedence over documentation.
B. Measuring vital signs is the priority because it helps identify any immediate complications from the fall, such as hypotension, pain, or neurological impairment. A sudden drop in blood pressure could indicate shock, while tachycardia may suggest distress or injury. Checking for changes in mental status, pain levels, and potential fractures ensures timely intervention. If abnormalities are found, further evaluation or treatment can be initiated promptly. Early assessment prevents worsening conditions and guides further actions.
C. Documenting the fall in the client's medical record is necessary for continuity of care but should be done after assessing and stabilizing the client. Medical documentation includes details about the fall, findings from the assessment, and any interventions provided. However, delaying assessment to document first could result in missed critical signs of injury. Proper documentation supports quality care but is secondary to ensuring the client’s immediate well-being. The nurse should prioritize physical assessment before recording the incident.
D. Notifying the provider is important, especially if the client has sustained injuries, is in pain, or has abnormal vital signs. However, calling the provider before performing an assessment can lead to incomplete or inaccurate reporting. The provider will need specific details about the client's condition, including neurological status, hemodynamics, and any visible injuries. Conducting an assessment first ensures that the provider receives the most relevant and useful information. Immediate assessment allows for timely intervention and prevents unnecessary delays in care.