A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits

Which of the following assessment findings should the nurse attend to right away?

Choice A rationale

Increasing the rate of IV fluids is the most appropriate nursing action based on the client's clinical presentation. The client has signs of hypovolemia, including tachycardia, low blood pressure with a narrow pulse pressure, and delayed capillary refill. An IV fluid bolus is often prescribed to improve intravascular volume and perfusion. Monitoring the client's response to increased IV fluids is essential to ensure effective treatment.

Choice B rationale

Administering pain medication is important for managing the client's comfort, but it is not the priority action in this situation. The client's vital signs indicate hypovolemia, which needs to be addressed promptly. Pain management can be considered after stabilizing the client's hemodynamic status.

Choice C rationale

Monitoring the client's urine output is important for assessing renal perfusion and fluid balance. However, with the current clinical presentation indicating hypovolemia, the priority action is to increase the rate of IV fluids to improve intravascular volume and perfusion.

Choice D rationale

Consulting with the healthcare provider is important for collaborative care and decision-making. However, the priority action in this situation is to address the client's signs of hypovolemia by increasing the rate of IV fluids. Immediate intervention is needed to stabilize the client's hemodynamic status before further consultations.

Choice A rationale

Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.

Choice B rationale

Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.

Choice C rationale

Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.

Choice D rationale

Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.

Choice E rationale

Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.