A nurse on a medical unit is admitting a client.

Exhibits

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Nurses' Notes

Day 1, 1600:

Client admitted from provider's clinic reporting shortness of breath, dry hacking cough, dizziness, and "heart racing."

States they are not able to sleep well on their back at night because of difficulty breathing.

Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S1, auscultated. Lower extremity edema noted, 2+ bilaterally, Radial and pedal pulses 1+ bilaterally.

Breathing rapid and shallow. Crackles auscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.

Client reports gaining 10 pounds in the past month.

Reports history of type 2 diabetes mellitus and hypertension.

A. A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B. Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C. A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D. A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.

Rationale for A: While contacting a shelter in another county might be a good long-term option, the client should prioritize preparing for an immediate, safe escape rather than focusing on geographic distance.

Rationale for B: Telling the client to leave immediately may not be feasible or safe. The client needs to be prepared with a well-thought-out plan, including knowing when and how to leave, based on the safest opportunity.

Rationale for C: Keeping a packed bag by the front door may alert the abuser and increase the risk of violence. Instead, the bag should be kept in a secure and hidden location to avoid raising suspicion.

Rationale for D: Rehearsing an escape route is a critical component of a safety plan. It ensures the client knows how to leave quickly and safely in case of an emergency, which is vital for their safety.