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

Nurses' Notes

Day 1, 12:00:

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

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The 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." The 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.

This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.

It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.

The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.

Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.

The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.

Veracity refers to the ethical principle of truthfulness and honesty in communication. By communicating truthfully about the adverse effects of the client's prescribed medications, the nurse is practising veracity. This means providing accurate and complete information to the client, enabling them to make informed decisions about their healthcare.

Beneficence refers to the obligation of healthcare professionals to act in the best interests of the client and promote their well-being. While the nurse's actions may align with beneficence by providing information about medication adverse effects, it is specifically veracity that is demonstrated in this scenario.

Justice pertains to fairness and equal treatment. Although important in healthcare, it is not directly related to the nurse's communication of adverse effects.

Autonomy refers to respecting and supporting the client's right to make their own decisions about their care. While the nurse's truthful communication about adverse effects supports the client's autonomy, it is the concept of veracity that specifically addresses honesty and truthfulness in communication.