A nurse is caring for an 84-year-old female client in her home following an investigation by Adult Protective Services.

Exhibits

Drag from the statement options to complete the sentence.
To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client’s:

Choice A rationale

Assisting the client to void before walking can prevent potential incontinence episodes, which might be embarrassing for the client. Additionally, a full bladder can increase the risk of falls due to discomfort or urgency to get to the restroom quickly.

Choice B rationale

While instructing the client about signs of orthostatic hypotension is important, it is not within the scope of practice for an unlicensed assistive personnel (UAP) to provide such instructions. This task falls under the responsibility of a licensed nurse.

Choice C rationale

Measuring the client's vital signs before walking helps to assess the client's baseline status and ensures that the client is stable enough to engage in physical activity. Any abnormal readings could indicate the need to postpone or modify the activity.

Choice D rationale

Reporting the onset of any dizziness or light-headedness is crucial for ensuring the client's safety during activity. These symptoms could indicate underlying issues such as orthostatic hypotension or other cardiovascular problems that need to be addressed promptly.

Choice E rationale

Determining if a gait belt is needed ensures that the client receives appropriate support while walking. A gait belt can provide additional stability and help prevent falls, especially for clients with limited tolerance for activity.

Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.

Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.

Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.

Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.

Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.

Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.

Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.

Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.