A nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data from the client.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

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and

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indicate manifestations of borderline personality disorder.

A. Current level of consciousness. Changes in mental status, such as confusion or decreased alertness, can indicate hypoxia, infection, or worsening respiratory distress. Given the client’s history and symptoms, altered consciousness requires immediate follow-up to assess for possible hypoxemia or sepsis.
B. Heart rate. While the heart rate of 104/min is slightly elevated, it is not critically abnormal. Tachycardia can occur due to fever, anxiety, or respiratory distress, but it is not the most urgent concern compared to other findings.
C. Respiratory rate. The client’s respiratory rate of 30/min is significantly elevated, indicating possible respiratory distress. Increased work of breathing suggests inadequate oxygenation or potential pneumonia, requiring immediate evaluation and intervention.
D. Chronic health condition. The client has Parkinson’s disease and a history of smoking, both of which are important considerations in their overall care but do not require immediate intervention in the current scenario.
E. Tremors. Tremors are a common symptom of Parkinson’s disease and do not indicate an acute emergency. They do not require urgent follow-up in this case.
F. Oxygen saturation level. An oxygen saturation of 89% on room air is concerning, as it indicates hypoxemia. Immediate intervention, such as supplemental oxygen and further respiratory assessment, is necessary to prevent further deterioration.

A. Use a moisturizing soap to clean the skin around the client's stoma. Using moisturizing soap is not recommended because it can leave a residue that interferes with the adhesion of the skin barrier. A mild, non-moisturizing soap should be used to cleanse the area, followed by thorough rinsing and drying.
B. Change the client's ostomy appliance 1 hr after breakfast. Changing the ostomy appliance should ideally be done when the stoma is less active, which is usually before meals or several hours after meals. Changing it right after breakfast may lead to difficulty managing output if the stoma is still active.
C. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. The skin barrier opening should be cut to fit the stoma snugly, typically 1/8 inch (0.3 cm) larger than the stoma size, not 0.5 inches. A larger opening can lead to skin irritation and leakage.
D. Empty the client's ostomy pouch before removing the skin barrier. This is an important step to minimize the risk of spills and make the process more manageable. Emptying the pouch ensures that the contents do not leak out during the change, helping maintain a clean and safe environment during the procedure.