The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.

A) Nutritionist:
While a nutritionist can provide valuable advice on feeding, including breastfeeding or formula feeding, the primary issue here is not related to nutritional guidance but rather the financial concern about paying for baby formula. A nutritionist may provide support, but they are not typically responsible for addressing financial needs or coordinating resources for assistance.

B) Case manager:
The case manager is the most appropriate team member to refer to in this situation. A case manager is responsible for assessing the client’s needs and connecting them with resources such as financial assistance, community support programs, or social services. Since the client is unable to afford baby formula, the case manager can help by referring the client to programs that may provide formula at no cost or at a reduced price, such as the Women, Infants, and Children (WIC) program.

C) Primary care provider:
The primary care provider may offer support and referrals but would generally not be the first point of contact for addressing financial barriers to obtaining baby formula. The primary care provider can provide medical advice related to the client's postpartum care and the infant's health, but they are not typically the best person to address financial concerns directly.

D) Pediatric nurse practitioner:
A pediatric nurse practitioner focuses on providing care for the child, not necessarily addressing the financial needs of the family. While they can provide guidance on infant care and feeding, the issue of financial support for formula is outside their role. The case manager would be the more appropriate referral to assist with financial concerns.