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:

8 lb is not an appropriate weight gain for this client because it falls below the recommended range.

Choice B Reason:

32 lb is excessive weight gain for a client with a prepregnancy BMI of 30.5. Excessive weight gain during pregnancy can increase the risk of various complications, including gestational diabetes, hypertension, and larger-than-average birth weight.

Choice C Reason:

16 lb is within the recommended range for weight gain during pregnancy for a client with a prepregnancy BMI of 30.5. This falls in the range of approximately 11 to 20 pounds (5 to 9 kilograms) of weight gain.

Choice D Reason:

24 lb is above the upper limit of the recommended weight gain range for a client with a prepregnancy BMI of 30.5. It exceeds the upper limit of approximately 20 pounds (9 kilograms) of weight gain.

Choice A Reason:

Telling the client to discuss the decision with her family implies that the family should influence or make the decision for the client. The decision to continue or discontinue treatment is a personal one that the client should make based on their own values and preferences.

Choice B Reason:

Supporting the client's decision to stop the treatment is correct. When a client with end-stage kidney disease decides to stop dialysis treatment, it's essential for the nurse to respect the client's autonomy and support their decision. The client has the right to make decisions about their own healthcare, including the decision to discontinue a treatment that is no longer aligned with their goals and wishes.

Choice C Reason:

Discussing alternative treatment methods may be appropriate in some cases, but if the client has made an informed decision to stop dialysis, the focus should be on respecting and supporting that decision rather than presenting alternatives.

Choice D Reason:

Involving the facility chaplain may be beneficial if the client desires spiritual or emotional support during this difficult decision-making process, but it should be at the client's request, not imposed by the nurse.