A nurse is collecting data from a client who has been admitted with suspected appendicitis. Which of the following findings is the nurse's priority to report to the provider?

Choice A reason: This is not an appropriate action because keeping the lights dimmed can increase the risk of falls, confusion, or agitation in the client who has Alzheimer's disease. The nurse should provide adequate lighting and reduce glare and shadows in the client's room and environment.

Choice B reason: This is not an appropriate action because alternating the client's daily routine can cause stress, anxiety, or frustration in the client who has Alzheimer's disease. The nurse should maintain a consistent and structured routine and schedule for the client and provide cues and reminders as needed.

Choice C reason: This is an appropriate action because participating in reminiscence therapy with the client can enhance their cognitive function, mood, and self-esteem by stimulating their long-term memory and encouraging them to share their past experiences, feelings, and values. The nurse should use photos, music, or objects that are meaningful to the client and listen actively and respectfully.

Choice D reason: This is not an appropriate action because raising the four side rails on the client's bed can be considered a form of restraint that can harm or injure the client who has Alzheimer's disease. The nurse should use alternative measures to ensure the client's safety and comfort, such as lowering the bed, using a bed alarm, or providing frequent supervision.

Choice A reason: This is not an appropriate intervention because monitoring the neurovascular status of the client's affected limb every 8 hours is not frequent enough to detect any signs of impaired circulation, sensation, or movement in the limb that may result from injury, infection, or compartment syndrome. The nurse should monitor the neurovascular status of the client's affected limb at least every 2 hours and compare it with the unaffected limb.

Choice B reason: This is not an appropriate intervention because applying 4.5 kg (10 lb) traction weight to the distal end of the fixator is not indicated for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should avoid applying any weight or force to the fixator unless prescribed by the provider.

Choice C reason: This is an appropriate intervention because administering pain medication 30 minutes prior to pin care can reduce the discomfort and anxiety that the client may experience during the procedure, which involves cleaning and inspecting the pins and wires that hold the fracture fragments in place. The nurse should administer analgesics as prescribed and use aseptic technique and sterile equipment for pin care.

Choice D reason: This is not an appropriate intervention because adjusting the clamps on the device's frame daily is not within the scope of practice of a nurse who is caring for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should leave the clamps and screws on the device untouched and notify the provider if they become loose or damaged.