A nurse is assisting with the care of a client on a medical surgical unit who was admitted from the emergency department.

Exhibits

For each assessment finding on Day 2 click to specify if the finding is due to lisinopril, carvedilol, or furosemide. Each finding may be related to more than 1 medication.

A. Contact children and youth services. There is no indication that the client is a minor. Mandatory reporting to child protective services applies to minors, but in the case of an adult client, reporting sexual assault is the client’s decision unless required by law (such as in cases involving incapacitated individuals or threats to public safety).
B. Administer sexually transmitted infection prophylaxis. Clients who have experienced sexual assault should be offered prophylactic treatment for sexually transmitted infections (STIs), including chlamydia, gonorrhea, and trichomoniasis, in accordance with CDC guidelines. Post-exposure prophylaxis for HIV may also be considered based on risk factors.
C. Provide resources to the client for the local Alcoholics Anonymous chapter. The client reports social drinking but has not indicated problematic alcohol use or a desire for treatment. Providing unsolicited resources for Alcoholics Anonymous may not be appropriate in this situation.
D. Maintain a safe and private environment for the client. Ensuring privacy and a safe space is essential for clients who have experienced trauma. The nurse should provide emotional support, minimize interruptions, and allow the client to make decisions regarding care.
E. Request a consult for case management. Case management services can assist with legal considerations, follow-up care, counseling referrals, and safety planning. The nurse should initiate a referral to support the client’s needs.
F. Provide resources for local support services. Sexual assault survivors should receive information about crisis hotlines, advocacy groups, counseling services, and other community resources that can offer emotional and legal support.

A. Weight loss: Fluid overload is characterized by excessive fluid retention rather than loss. Weight gain is a more common finding due to fluid accumulation in tissues. Weight loss would be associated with dehydration, malnutrition, or inadequate caloric intake rather than fluid overload.
B. Decreased blood pressure: Fluid overload typically leads to increased blood pressure due to excess circulating volume. Decreased blood pressure is more commonly seen in dehydration or conditions that result in significant fluid loss, such as hemorrhage or severe diarrhea.
C. Decreased skin turgor: Poor skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, clients may exhibit edema, moist skin, and increased vascular volume instead of signs of dehydration.
D. Crackles heard in the lungs: Crackles in the lungs indicate pulmonary congestion due to excess fluid accumulation, which can occur with fluid overload. Increased intravascular volume leads to leakage of fluid into the alveoli, causing difficulty breathing, shortness of breath, and pulmonary edema in severe cases.