The nurse is performing a mobility assessment with a client. Which component(s) should the nurse include in the assessment? Select all that apply.

Rationale:
A. Tell the client to discuss the medication side effects with the healthcare provider (HCP): Encouraging the client to communicate side effects with the HCP ensures safe management of the antidepressant regimen. The provider can evaluate whether dose adjustment, switching medications, or additional interventions are appropriate, promoting adherence and safety.

B. Tell the client that the medication's side effects will most likely dissipate over time: While some side effects may improve, this statement does not address the client’s concern about discontinuation or provide a plan for safe action. It may minimize the client’s experience.

C. Inform the client that gradual tapering must be used to discontinue the medication: Tapering is correct for safe discontinuation, but the nurse should first involve the HCP in planning changes. Advising tapering independently could lead to unsupervised medication changes.

D. Remind the client that feeling better is the therapeutic effect of the medication: Although accurate, this statement does not address the client’s concern about side effects or provide guidance for safe continuation or discontinuation. It may seem dismissive.

Rationale:

• Cellulitis: The client presents with redness, warmth, swelling, and tenderness in the left lower leg, which are hallmark signs of cellulitis. The history of a small cut from shaving provides a portal of entry for bacterial infection. The acute onset over several days and localized inflammation support a diagnosis of cellulitis rather than vascular or neuropathic causes.

• Left lower leg erythema: Erythema is a key clinical indicator of inflammation and infection in cellulitis. The asymmetry between legs and localized redness around the ankle and foot highlights the affected area. Combined with swelling and warmth, erythema supports the diagnosis and guides monitoring for progression.

• Break in skin: The presence of a small scab or cut provides a pathway for bacterial entry, explaining the localized infection. Skin trauma is a common predisposing factor for cellulitis, especially in clients with diabetes or peripheral vascular disease. Identification of the break is important for understanding etiology and planning treatment.

• Deep vein thrombosis: Although DVT can cause unilateral leg swelling and pain, it usually does not produce erythema that is warm and localized near a small cut. The client also has no risk factors like recent immobilization or sudden onset swelling in this case. Assessment findings favor an infectious cause rather than thrombotic obstruction.

• Intermittent claudication: Intermittent claudication causes pain in the legs during exertion due to peripheral arterial disease, but it does not present with redness, warmth, or localized swelling. The client’s pain is associated with leg tightness and erythema, not exertion-related ischemia. Vascular compromise is not the primary concern here.

• Hyperglycemia: While the client’s blood glucose of 252 mg/dL is elevated, hyperglycemia alone does not explain the localized leg redness, swelling, and warmth. Hyperglycemia may contribute to poor healing and increased infection risk, but it is not the cause of the acute leg findings.

• Capillary refill greater than 3 seconds: Prolonged capillary refill indicates peripheral perfusion delay but does not specifically diagnose cellulitis. It may reflect underlying vascular disease or edema, but the primary indicators of cellulitis are erythema and skin break.

• Pain: 2 on a 0 to 10 scale, bilateral lower legs described from neuropathy: The mild, bilateral neuropathic pain is chronic and unrelated to the acute infection in the left leg. It does not support a diagnosis of cellulitis, which is characterized by localized pain and tenderness at the infection site.