A nurse is reviewing the electronic medical records of clients following the implementation of a quality improvement plan to reduce health care associated infections.

Exhibits

Select the three clients whose findings indicate the program is effective.

A. Asking the client about the presence of pain. This is part of the assessment phase, as it involves gathering data.
B. Reinforcing teaching about the client's diagnosis. Teaching is part of the implementation phase, where planned interventions are carried out.
C. Establishing the priorities of client care. This is part of the planning phase, where care priorities are determined.
D. Comparing the client's current laboratory values to previous results. This is part of the evaluation phase, where the nurse assesses progress toward goals.

Client 1 (First Priority):

• Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
• Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.

Client 2 (Lower Priority):

• Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
• Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.

Client 3 (Lowest Priority):

• Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
• Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.