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. Antibiotic medication can be taken with or without food.

This statement is not specifically relevant to the discharge teaching for this client with pneumonia. However, the nurse should provide specific instructions regarding the administration of the antibiotic (cefazolin), which is typically administered intravenously in a healthcare setting and may not be taken orally at home.

B. The steroid dose will decrease each day.

Explanation: This information ensures that the client and caregiver are aware of the tapering regimen for the steroid medication (prednisone), which is essential to prevent adrenal insufficiency and other potential adverse effects associated with abrupt discontinuation.

C. Adjust the oxygen flow rate as needed to ease breathing.

Explanation: This information educates the client and caregiver on how to manage oxygen therapy effectively at home, ensuring optimal oxygen delivery and respiratory support.

D. Antibiotic therapy should be taken for 10 days.

The duration of antibiotic therapy for pneumonia depends on the specific antibiotic prescribed and the severity of the infection. The nurse should provide clear instructions based on the healthcare provider's prescription and guidelines.

E. Store the oxygen cylinder wrench with the oxygen tank.

While storing the oxygen cylinder wrench with the oxygen tank is a good practice, it is not directly related to discharge teaching for this client with pneumonia.

F. Steroid medication should be taken in the morning.

Explanation: Taking steroid medication (prednisone) in the morning helps minimize disruption of the body's natural cortisol rhythm and reduces the risk of insomnia associated with steroid use.

G. Ensure the oxygen delivery system is at least 8 feet from any heat source.

Explanation: Proper storage and placement of the oxygen delivery system reduce the risk of fire hazards associated with oxygen therapy, promoting safety within the home environment.

A. "Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.

B. "Have you thought about harming yourself?"

This response directly addresses the client's statement expressing thoughts of dying and allows the nurse to assess the client's risk of self-harm or suicide. It opens up a dialogue about the client's feelings and intentions, which is crucial for ensuring their safety and providing appropriate support and intervention.

C. "You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.

D. "Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.