A 25-year-old patient is admitted to the ambulatory surgery unit to receive two units of whole blood.

The patient has anemia, systemic lupus erythematosus, hypertension, schizophrenia, and primary hypothyroidism.

The patient’s vital signs are BP 100/68, P 110, R 24, T 99.1 °F, O2-97%. The patient reports experiencing shortness of breath with exertion, fatigue, dizziness when standing, and an intolerance to cold temperatures.

Initial labs indicate an Hgb of 6.8, an Hct of 21.2, a CRP of 38, an albumin of 14, and an iron level of 9. The patient’s current medications include hydroxychloroquine 200 mg one BID, amlodipine 10 mg one PO daily, Citalopram 20 mg one PO daily, Lisinopril 20 mg one PO daily, sertraline 50 mg one daily, levothyroxine 75 mg one PO daily, Ferrous sulfate 30 mg one PO TID, and quetiapine 100 mg one PO HS. Which patient assessment findings require immediate follow-up by the nurse at this time? (Select all that apply)

Choice A rationale:
Plague is a highly contagious and often fatal disease caused by the bacterium Yersinia pestis. It is transmitted to humans through the bites of infected fleas or by direct contact with infected animals or their tissues.
Plague can cause severe illness and death, even with prompt treatment. The mortality rate for untreated plague is 50-60%. Therefore, it is incorrect to state that plague produces a mild illness and generally has a low mortality rate.
Choice C rationale:
Smallpox is a highly contagious and deadly disease caused by the variola virus. It was eradicated in 1980, but there is still a risk that it could be used as a bioweapon.
Most people under the age of 40 have not been vaccinated against smallpox and therefore have no immunity to the disease. Therefore, it is incorrect to state that the majority of Americans have adequate innate immunity to smallpox.
Choice D rationale:
Safer food preparation practices have helped to decrease the incidence of foodborne illnesses.
However, foodborne illnesses can still be spread through international travel. Travelers can be exposed to contaminated food or water in other countries.

Therefore, safer food preparation practices do not eliminate the risk of foodborne illnesses being spread through international travel.

Choice A rationale:
While adequate hydration is important for overall health and urinary function, it does not directly address the priority nursing diagnosis of urinary incontinence. Increased fluid intake without addressing the underlying incontinence can actually exacerbate the problem by increasing urine output.
It's crucial to assess for signs of urinary retention or incomplete bladder emptying, as excessive fluid intake can worsen these conditions.
Individualized fluid intake goals should be established based on the client's overall health status, bladder capacity, and fluid balance.
Choice B rationale:
Satisfaction with incontinence products can improve comfort and quality of life, but it does not necessarily indicate that the underlying issue of incontinence has been resolved.
It's important to evaluate the effectiveness of incontinence products in managing leakage and preventing skin breakdown, but they should not be considered a definitive solution for incontinence.
Explore other interventions to address the root cause of incontinence, such as bladder training, pelvic floor muscle exercises, or medications.
Choice C rationale:
Increased activity and socialization can be positive outcomes of effective incontinence management, but they are not direct measures of the priority nursing diagnosis.
Improved social engagement and activity levels might reflect a reduction in incontinence episodes and increased confidence, but they should not be the sole indicators of success.
Assess for specific changes in incontinence frequency, severity, and impact on daily life to more accurately gauge progress.
Choice D rationale:
Intact, healthy skin in the perineal area is a direct and objective indicator that a priority nursing diagnosis of urinary incontinence has been met.
It demonstrates that the interventions implemented to manage incontinence have been effective in preventing skin breakdown and irritation, which are common complications of incontinence.
This finding aligns with the goal of maintaining skin integrity and preventing infection, which are essential aspects of incontinence care.