A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

Choice A Reason:

Suggesting that the client assist with meal planning may be appropriate, but it's not the first priority. Monitoring the client's eating behaviors and safety during meals takes precedence.

Choice B Reason:

Observe the client during and after meals. When caring for a client with bulimia nervosa, the initial priority is to monitor the client during and after meals to assess their eating behaviors and the potential for purging or other disordered eating habits. This helps ensure the client's safety and can provide valuable information for the treatment team. Once immediate safety concerns are addressed, the nurse can proceed with other aspects of care, such as assisting with meal planning, providing education on coping strategies, and referring the client to support groups as appropriate.

Choice C Reason:

Instructing the client about effective coping strategies is an important part of the treatment plan, but it's not the immediate priority. Ensuring the client's safety during meals is more critical initially.

Choice D Reason:

Referring the client to a support group can be a valuable part of long-term treatment, but it's not the first step. Monitoring and addressing immediate eating behaviors and safety come first.

Choice A Reason:

Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.

Choice B Reason:

Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.

Choice C Reason:

Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.

Choice D Reason:

This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.