A nurse is caring for a client.

Exhibit 1

Medical History

0800:

Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension.

Client has a BMI of 32.

Client has a family history of colon cancer.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)

A. Ensure that the client's bed is in the lowest position.

Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.

B. Assess skin temperature and color before applying the restraints.

This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.

C. Attach the client's restraints to the bed rail.

Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.

D. Pad bony prominences before applying the restraints.

Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.

E. Secure restraints to allow three fingers to slide under the restraints.

Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.

A. The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

B. The client coughs frequently while eating.

Coughing frequently while eating can indicate a risk of aspiration, which is a serious concern in stroke patients with left-sided weakness. Aspiration can lead to pneumonia and other respiratory complications. Therefore, it is crucial for the nurse to address this finding promptly to prevent potential respiratory compromise.

C. The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

D. The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.