A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Rationale for Correct Choices:

• Compartment syndrome: The client shows hallmark signs: pain unrelieved by medication (rated 9/10), cool foot, 2+ edema, numbness, absent pedal pulses, delayed capillary refill, and inability to move the foot. These findings indicate increased pressure within a muscle compartment that compromises circulation and nerve function, requiring emergency intervention to prevent tissue necrosis or amputation.
• Osteomyelitis: A rapidly rising temperature (up to 38.9°C), elevated WBC count (28,000/mm³), and presence of drainage from the splint site suggest a localized bone infection. Osteomyelitis can develop from an open fracture, especially post-surgery, and early detection is critical for avoiding systemic infection or bone destruction.

Rationale for Incorrect Choices:

• Deep vein thrombosis (DVT): While immobilization increases DVT risk, the scenario lacks classic signs like unilateral calf swelling, warmth, erythema, or a positive Homan's sign. Additionally, pulses are absent in the foot, not consistent with a DVT presentation, which typically does not affect distal pulses.
• Fat embolism: The client does not exhibit hallmark signs such as acute respiratory distress, petechial rash, or altered mental status. Although long bone fractures pose a fat embolism risk, no findings suggest embolic movement or pulmonary compromise in this case.

Rationale:

A. Action: The action stage involves actively implementing strategies to change behavior. Since the group is already in the process of reducing pesticide use, they are taking concrete steps toward achieving their goal, which defines the action phase.

B. Maintenance: Maintenance occurs after a behavior has been successfully adopted and sustained over time. The group has not yet reached this phase, as they are still actively working on the change rather than maintaining it.

C. Contemplation: Contemplation is the stage where individuals or groups are considering a change but have not yet committed to or started the process. The group’s involvement in reducing pesticide use suggests they have moved beyond this phase.

D. Preparation: Preparation includes making plans and gathering resources to initiate change. While the group may have gone through this stage, the current activity of reducing pesticide use indicates they have progressed to the action stage.