Exhibits

Click to highlight the aspects of the assessment that require urgent attention.

0900

Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.

A. "I always shake the inhaler several times before I start": This comment suggests that the client may be swallowing the medication instead of properly inhaling it. Inhalers are designed to deliver medication directly to the lungs, and swallowing the medication reduces its effectiveness and may cause systemic side effects, such as nausea. Proper inhaler technique requires the client to inhale deeply while pressing the inhaler and to avoid swallowing the medication.

B. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away": While swallowing the medication is not the intended action for inhalers, feeling nausea may indicate improper use. However, this is not the most critical misuse. It suggests the client may not be inhaling the medication correctly, but this answer does not highlight the most important mistake, which is the delay in using the inhaler.

C. "I never use the inhaler unless I am feeling really short of breath": While this comment reflects underuse of the inhaler, it does not indicate incorrect technique. However, it does suggest a need for education on the importance of preventive or maintenance use of inhalers, depending on the prescribed regimen.

D. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best": Difficulty with proper inhalation and breath-holding is common, but this can be addressed by using inhalation techniques or devices like a spacer. This response does not indicate a fundamental misuse of the inhaler like waiting too long to use it.

Priority Need: Pain: The client reports severe, constant pain (10/10) in the left arm and moderate pain (3/10) in the right knee, which must be managed immediately to provide comfort and avoid further complications such as increased blood pressure or stress response.

Prevention of Venous Thromboembolism (VTE): Given the client's limited mobility after the fall and his high BMI, he is at increased risk for venous thromboembolism, which requires preventive measures such as early mobilization or anticoagulation therapy.