A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority?

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.

A. BMI of 20: While a BMI of 20 is on the lower end of the normal range, it does not necessarily indicate a high risk for pressure injuries. Extreme low BMI may pose a risk, but a BMI of 20 alone is not a definitive factor in increasing pressure injury risk compared to the other listed conditions.
B. Peripheral neuropathy: Peripheral neuropathy impairs sensation in the skin, which reduces the client’s ability to feel pressure, pain, or discomfort. This diminished sensory perception increases the risk of developing pressure injuries as the client might not be aware of or respond to pressure-related issues.
C. Immobility: Immobility, or limited mobility, significantly raises the risk of pressure injuries because it prevents the client from frequently changing positions. Prolonged pressure on specific body areas can impede blood flow and lead to skin breakdown.
D. Hypoperfusion: Hypoperfusion indicates reduced blood flow to tissues, which can contribute to tissue ischemia and increase the risk of pressure injuries. Inadequate blood flow prevents adequate oxygen and nutrient delivery to the skin, making it more susceptible to damage.