A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

 

Choice A reason:

Monitoring the client’s calf for edema is important in assessing for complications such as deep vein thrombosis (DVT) or compartment syndrome, but it is not the primary technique for assessing neurovascular status. Edema can indicate fluid accumulation and potential vascular issues, but it does not directly assess the nerve function or blood flow to the extremity.

Choice B reason:

Palpating the femoral pulse is crucial in assessing the neurovascular status of a client with a femur fracture. The femoral pulse provides information about the blood flow to the lower extremity. A strong, palpable pulse indicates good arterial blood flow, while a weak or absent pulse may suggest vascular compromise, which requires immediate attention. This assessment helps ensure that the blood supply to the limb is adequate, which is vital for healing and preventing complications.

Choice C reason:

Measuring the circumference of the thigh can help monitor for swelling and changes in muscle mass, but it is not a direct assessment of neurovascular status. While it can provide useful information about the extent of swelling or atrophy, it does not evaluate the nerve function or blood flow directly.

Choice D reason:

Instructing the client to wiggle his toes is a useful technique to assess motor function and nerve integrity. However, it is not sufficient on its own to assess the entire neurovascular status. It should be part of a comprehensive assessment that includes checking pulses, sensation, and capillary refill.

Choice A reason:

The statement “The nurse identifies a broken piece of equipment” is important for safety and should be reported to the appropriate department for repair or replacement. However, it does not typically require an incident report unless the broken equipment caused harm or had the potential to cause harm to a patient. Incident reports are generally used to document events that are not consistent with the routine operation of the healthcare unit or the standard care of a patient.

Choice B reason:

The statement “The nurse has a disagreement with the nursing supervisor about inadequate staffing” reflects an internal issue that should be addressed through appropriate channels, such as a staff meeting or a discussion with human resources. It does not typically require an incident report unless the disagreement led to a situation that compromised patient safety or care. Incident reports are meant to document events that directly affect patient care and safety.

Choice C reason:

The statement “A staff member does not show up to work her assigned shift” is a staffing issue that should be managed by the nursing supervisor or the staffing coordinator. While it can affect the workflow and staffing levels, it does not usually require an incident report unless it directly impacts patient care or safety. Incident reports are used to document specific events that deviate from standard care practices and have the potential to harm patients.

Choice D reason:

The statement “A client discovers that his dentures are missing” is a situation that requires an incident report. The loss of a client’s personal belongings, especially something as essential as dentures, can significantly impact the client’s well-being and quality of care. Documenting this incident helps to investigate the circumstances, prevent future occurrences, and ensure that appropriate measures are taken to address the client’s needs. Incident reports are crucial for tracking and addressing issues that affect patient care and safety.