A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

Exhibits

Which of the following are the most appropriate interventions for this client? Select all that apply.

Choice A rationale

Informing the client that the nurse is busy and will talk to him later is a professional and appropriate response. This approach acknowledges the client's need for attention while setting a clear boundary that respects the nurse's current responsibilities. It also provides a time frame for when the client can expect to receive attention, which can help reduce anxiety or agitation. This method promotes orderly and efficient care without compromising the needs of the newly admitted client.

Choice B rationale

Putting the client's behavior on extinction by not acknowledging it might seem effective, but it can lead to feelings of being ignored or dismissed. This approach is not therapeutic in a psychiatric setting, where clients often require validation and structured interactions. Ignoring a client's request can escalate the behavior or contribute to a sense of isolation. Therapeutic communication involves active listening and responding appropriately to all clients.

Choice C rationale

Introducing the client to the newly admitted client and asking him to join the conversation can be disruptive and inappropriate. This action may not address the urgency of the client's concern and can intrude on the privacy and focus needed for the newly admitted client. It is important to maintain a structured and private environment for admissions to ensure that the new client feels supported and understood.

Choice D rationale

Encouraging the client to go to the nurse's station and talk with another nurse may not be practical, especially if the other nurses are also occupied. This response can seem dismissive and may not adequately address the client's immediate concern. It is more effective to provide a clear time frame or alternative solution for when the client will receive attention. Proper delegation requires ensuring that the alternative option is available and can provide the necessary support.

Choice A rationale: Acute appendicitis is most likely based on the history of sudden onset of severe abdominal pain localized to the right lower quadrant, nausea, vomiting with green bile, and tenderness on physical examination. The ultrasound findings of right lower quadrant tenderness further support this diagnosis. The client's vital signs, including tachycardia and tachypnea, are consistent with the stress and pain caused by acute appendicitis.

Choice B rationale: Ectopic pregnancy is less likely as the client has a negative pregnancy test and reports regular menstrual cycles with her last period occurring one week ago. Additionally, her symptoms are more typical of appendicitis.

Choice C rationale: Ovarian cyst rupture would typically present with sudden onset of pelvic pain, often associated with menstrual irregularities or a history of ovarian cysts. However, the client's presentation and diagnostic results strongly point towards acute appendicitis.

Choice D rationale: Acute gastritis generally presents with epigastric pain, nausea, and vomiting. However, the localization of pain to the right lower quadrant and the ultrasound findings make appendicitis a more likely diagnosis in this case.