A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

a. Decreased level of consciousness:

This finding is concerning and may indicate worsening neurological status, increased intracranial pressure, or impending herniation. A decreased level of consciousness requires immediate evaluation by the provider to assess for neurological deterioration and potential interventions to stabilize the client's condition.

b. Increased temperature:

While an increased temperature (fever) is commonly associated with meningitis due to the inflammatory response, it may not necessarily require immediate reporting unless it is extremely high or accompanied by other concerning symptoms. Fever management is important, but it may not warrant immediate provider notification unless it is severe or refractory to treatment.

c. Generalized rash over trunk:

A generalized rash can be associated with certain types of meningitis, such as meningococcal meningitis, and may indicate sepsis or disseminated infection. However, it may not always require immediate provider notification unless it is accompanied by other concerning symptoms or signs of systemic illness.

d. Report of photophobia:

Photophobia (sensitivity to light) is a common symptom of meningitis and is often reported by clients. While photophobia is significant in the context of meningitis, it may not require immediate provider notification unless it is severe or accompanied by other worrisome neurological symptoms.

a. Document in the client’s chart that an incident report has been filed:

Documenting that an incident report has been filed is an important step in the process of addressing the client's complaint. It ensures that there is a record of the incident and initiates the appropriate follow-up procedures.

b. Call risk management to interview the client:

In long-term care facilities, risk management departments are responsible for investigating incidents and ensuring that appropriate measures are taken to prevent future occurrences. In this situation, involving risk management may be necessary to conduct a thorough investigation.

c. Contact the nurse manager:

The nurse manager is responsible for overseeing the nursing staff and ensuring that quality care is provided to clients. Contacting the nurse manager allows for immediate notification of the incident and enables them to initiate the appropriate steps to address the situation.

d. Reassure the client that the staff is well trained:

While it's important to provide reassurance to the client, simply reassuring them without taking any further action may not adequately address their concerns or prevent similar incidents from occurring in the future.