A nurse is collecting data from a client who is immobile and has a potential deepvein thrombosis.
Which of the following findings should the nurse report to the provider?

The correct answer is choice C, D, and E.

Choice A rationale:A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale:A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale:A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale:A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale:A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.

The correct answer is choice A. Use a communication board to interact with the client.

A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.

This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.

Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.

Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.

It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.

Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.

It uses facial expressions to rate the severity of pain in children from 0-103.

It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.