A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

c. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

d. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.