A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

A. "Enjoy the time you have and do the things you want to do":

While this response may seem supportive, it does not address the client's expressed desire for aggressive treatment. It is important for the nurse to acknowledge the client's wishes and provide appropriate support and information to help them make decisions about their care.

B. "Hospice care is the best thing for you at this time":

While hospice care may be appropriate for some clients with terminal illnesses, it is not appropriate to assume that it is the best option for every client. The nurse should not impose their own beliefs or preferences onto the client and should instead support the client in exploring their options and making decisions based on their individual needs and preferences.

C. "You need to understand that you have very little time left":

This response may be seen as dismissive or insensitive to the client's wishes for aggressive treatment. It does not acknowledge the client's autonomy or right to make decisions about their own care. The nurse should approach the situation with empathy and respect for the client's wishes, while also providing support and information to help them make informed decisions.

D. "I will contact your provider to discuss your options."

The client has expressed a desire for aggressive treatment, and it is important for the nurse to respect the client's autonomy and preferences. By stating that they will contact the provider to discuss the client's options, the nurse ensures that the client's wishes are communicated effectively and that they receive appropriate information and support to make informed decisions about their care.

A. A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.

B. Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.

C. A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.

D. A sharp decrease in blood pressure: This choice is indicative of an understanding of possible anaphylaxis. Anaphylaxis can cause a rapid and severe drop in blood pressure, known as hypotension. This drop in blood pressure is often a key feature of anaphylaxis and can lead to symptoms such as dizziness, fainting, confusion, and shock.