A client in an outpatient pain management clinic reports that their leg pain began 1 year ago after an injury that affected the spinal nerves. The pain has an intense sharp quality "like an electric shock". The client rates the pain level 9 on (0-10) scale after taking opioids & non-steroidal anti-inflammatory agents and receiving acupuncture. What are appropriate descriptors of the pain for the nurse to document? (SELECT ALL THAT APPLY)

A. Call the supervisor: While it's important to involve the supervisor if the situation escalates or if additional support is needed, calling the supervisor should not be the nurse's initial response. The nurse should first attempt to address the behavior directly with the client.

B. Limit the amount of time spent in the client's room: Limiting the time spent in the client's room may seem like a temporary solution to avoid the uncomfortable situation, but it does not address the underlying issue of inappropriate behavior. The nurse should address the behavior directly to attempt to resolve it rather than avoiding the client's room altogether.

C. Have a male nursing assistant provide care: Assigning care based on gender may not be feasible or appropriate in all situations. It also does not address the underlying behavior of the client making inappropriate sexual comments. Additionally, it may not be fair to the male nursing assistant to assign care based on the client's behavior.

D. Address the behavior and ask that it stop: This is the most appropriate initial response. The nurse should directly address the client's behavior by setting clear boundaries and expressing that the sexual comments are inappropriate and unacceptable. The nurse can assertively communicate that such behavior will not be tolerated and ask the client to stop. This approach empowers the nurse to assert professional boundaries and encourages respect for both the nurse and other healthcare providers.

A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.

B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.

C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.

D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.