A nurse is caring for a client.

Vital Signs.

1600: Nurses' Notes.

Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.

Respiratory rate 18/min.

Pulse oximetry 98% on room air.

1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.

Respiratory rate 26/min.

Pulse oximetry 92% on room air.

1600: Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout.

1630: Client reports itching on the chest and has urticaria over the chest and trunk.

Client states they are having difficulty swallowing and feel as if there is a lump in their throat.

Bilateral breath sounds with scattered wheezing heard throughout.

Vital Signs.

Nurses' Notes.

Medication Administration Record.

Cefaclor 500 mg PO q8h.

Select the 3 findings that require immediate follow-up.

Choice A rationale:

Tell the APs they are acting immature. Telling the APs that they are acting immature is a judgmental and unhelpful approach. It does not demonstrate conflict resolution but rather exacerbates the conflict. This choice is not appropriate for resolving the situation.

Choice B rationale:

Allow the APs to resolve their issues. While allowing individuals to resolve their issues on their own can sometimes work, it is not always the best approach, especially in a healthcare setting where teamwork and patient care are paramount. In this scenario, the nurse should play an active role in resolving the conflict, making this choice less suitable.

Choice C rationale:

Confront the APs to discuss their argument. Confronting the APs to discuss their argument is a proactive approach to conflict resolution. It allows the nurse to address the issue, mediate the disagreement, and work towards a resolution. This choice is the most appropriate and demonstrates effective conflict resolution.

Choice D rationale:

Report the APs to the charge nurse. Reporting the APs to the charge nurse should be considered when the conflict cannot be resolved at the staff level, and it threatens patient care or safety. However, it should not be the first step in resolving a conflict between two individuals. It is a more formal and escalated approach, and in this case, choice C is a more suitable initial response.

Choice A rationale:

Ensuring that the television is on is not a recommended action when providing discharge teaching for an adolescent with a cognitive disorder and their parents. Television noise can be distracting and may hinder effective communication. The focus should be on clear, concise, and tailored communication to address the patient's and family's needs.

Choice B rationale:

Using short directive statements is a suitable approach when teaching a patient with a cognitive disorder and their parents. Patients with cognitive disorders may have difficulty processing complex information, so using concise and straightforward language can enhance understanding. It is essential to adapt teaching strategies to the individual's needs and abilities.

Choice C rationale:

Including medical slang in the teaching is not appropriate, as it can confuse and alienate patients and their families. The goal of discharge teaching is to ensure that the information provided is clear, easily understood, and accessible to the patient and their family. Using medical jargon or slang may hinder this objective.

Choice D rationale:

Including abstract imagery is not recommended when teaching a patient with a cognitive disorder. Abstract imagery can be challenging to understand, especially for individuals with cognitive impairments. Teaching materials should be concrete, straightforward, and tailored to the patient's cognitive abilities and comprehension levels.