A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

A. Vagus: The vagus nerve (cranial nerve X) is involved in regulating autonomic functions, such as heart rate and digestion. It does not play a significant role in controlling jaw movements or clenching.
B. Facial: The facial nerve (cranial nerve VII) controls facial expressions, such as smiling or frowning, and also contributes to taste sensation in the anterior two-thirds of the tongue. While it is related to facial motor function, it does not control the jaw muscles responsible for clenching.
C. Glossopharyngeal: The glossopharyngeal nerve (cranial nerve IX) is involved in taste sensation on the posterior one-third of the tongue, as well as in swallowing and salivation. It does not control the jaw muscles used for clenching.
D. Trigeminal: The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions related to chewing. It innervates the muscles of mastication, including those involved in clenching the jaw. The client’s jaw clenching is a direct manifestation of motor function associated with the trigeminal nerve.

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.