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

Nurses' Notes

Day 1, 12:00:

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

The client is soft-spoken, speaks almost in a whisper, and does not make eye contact with the nurse.

The 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." The 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.

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

This response allows the nurse to actively listen to the client, gain a better understanding of their concerns and reasons behind wanting to stop treatment, and open the door for a more in-depth conversation. It demonstrates a non-judgmental approach and creates an opportunity for the client to express their fears, concerns, or any other factors influencing their decision.

"I would feel the same way if I were you." This response reflects the nurse's personal opinion and may not accurately represent the client's thoughts or feelings. It does not encourage the client to explore their own feelings or provide an opportunity for open communication.

"Why do you think that would be a good choice?" This response may come across as confrontational and judgmental, potentially making the client defensive or shutting down communication. It does not facilitate a therapeutic conversation or encourage the client to express their emotions and concerns openly.

"You'll be cancer-free after you complete your treatments." This response may oversimplify the client's situation or offer false reassurance. It is important to acknowledge the client's feelings and concerns while providing accurate information and support, rather than making unrealistic promises about treatment outcomes.

The nurse should approach the client's expression of wanting to stop treatment with empathy, active listening, and an open mind to provide the necessary support, education, and resources to help the client make informed decisions about their healthcare.