A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

Choice A Reason:

The cause of death is determined and documented by the physician or medical examiner, not the nurse. Including this in the postmortem documentation by the nurse would be inappropriate as it is not within the nurse's scope of practice to make this determination.

Choice B Reason:

While the nurse may document the last set of vital signs before death, this is typically recorded in the patient's medical record at the time the vital signs are taken, not specifically in postmortem documentation. The focus of postmortem documentation is on the events and conditions after the death has been confirmed.

Choice C Reason:

The location of the identification tag is crucial in postmortem documentation to ensure proper identification of the deceased. This information helps in maintaining the integrity and identification of the body during transportation and handling by the mortuary or funeral home.

Choice D Reason:

Advance directives are part of the client's medical record and are used to guide care decisions while the client is alive. They are not typically included in postmortem documentation, as they pertain to the client's wishes regarding treatment prior to death, not after. The original documents should remain in the client's file.

Choice A Reason:

A client who has a femur fracture and reports numbness of the toes. In the given scenario, the nurse should prioritize seeing the client with a femur fracture who reports numbness of the toes. Numbness in the toes may indicate compromised circulation or nerve damage, which can be a serious complication of a femur fracture. Addressing this issue promptly is crucial to prevent further complications.

Choice B Reason:

A client with cirrhosis and severe pruritus, while uncomfortable, does not require immediate intervention in the same way that a potential circulation issue does.

Choice C Reason:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable and not in immediate distress. The nurse can see this client after addressing the more urgent situation.

Choice D Reason:

A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be monitored closely for signs of bleeding, but the issue is not as urgent as the potential nerve or circulation problem in the client with a femur fracture and numbness of the toes.