A nurse is a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.