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.

Explanation

C. The client has developed difficulty ambulating

The information about the client's difficulty ambulating is relevant to the interprofessional team because it may require input and collaboration from various healthcare professionals to address and manage the client's mobility issues. This information helps the team understand the client's current condition and plan appropriate interventions.

The client having state-sponsored health insurance in (option A) is incorrect because it is not directly relevant to the interprofessional team meeting unless it specifically impacts the client's healthcare options, resources, or access to care. However, it may be important to know for insurance-related discussions or considerations, depending on the purpose of the team meeting.

The client's next dressing change being scheduled in 4 hours in (option B) is incorrect because it is important information for the nurse's own clinical responsibilities, but it may not be directly relevant to the broader interprofessional team meeting unless it has implications for the client's overall care plan or requires input from other team members.

The frequency of the client's vital sign checks being every 8 hours in (option D) is incorrect because it is important for the nurse's routine monitoring and care, but it may not be the primary focus of the interprofessional team meeting unless there are specific concerns or changes in the client's vital signs that need to be addressed collaboratively.

In summary, the nurse should include information about the client's difficulty ambulating during the interprofessional team meeting, as it helps inform the team's discussions, interventions, and plans regarding the client's mobility and potential impact on their overall care.

c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is

a serious complication that requires immediate intervention.

Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.

Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.

Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may

be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.