A community health nurse is caring for a client who has noticed that their drinking water isn't clear and reports they haven't been feeling well.
The nurse should identify the client is at risk for which of the following conditions?

Choice A rationale:

Encouraging family members to call the client is a valuable emotional and social support, but it may not be as effective in reducing social isolation for a client at the end of life. While communication with loved ones is important, it may not fully address the client's need for personal interaction.

Choice C rationale:

Instructing the client to join an online support group can be a useful intervention to reduce social isolation, especially in cases where physical interaction is limited. However, it may not be as effective for all clients, as comfort with technology and online groups can vary. Additionally, it should be one of several strategies used to address social isolation.

Choice D rationale:

Asking the client's friends to text the client is a positive gesture, but it may not be as effective as scheduling home visits with the client. Text messages may not provide the same level of personal interaction and emotional support that physical visits can offer.

Choice B rationale:

Scheduling home visits with the client is the most effective intervention to reduce social isolation in a client at the end of life. It allows for in-person interaction, emotional support, and the opportunity to address the client's physical and emotional needs directly. Face-to-face contact can significantly improve the client's sense of connectedness and reduce feelings of isolation.

The correct answer is to select the following three findings that require immediate follow-up:C. Urticaria,D. Blood pressure at 1630, andE. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis.Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg).This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis.This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.