A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain.

Which of the following conditions in the client's history should the nurse identify as a contraindication?

The correct answer is D.

Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.

The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.

B. “I should discuss this document with my family after I sign it.”It is important for clients to discuss their advance directives with their family members to ensure that their wishes are understood and respected. This helps prevent confusion and ensures that family members are aware of the client’s preferences for end-of-life care.

Incorrect Options:

A. “I am not allowed to change my mind once I sign this document.”Clients can change or revoke their advance directives at any time as long as they are competent to do so.

C. “My partner needs to be present when I sign this document.”While it is a good idea to have a witness, it is not necessary for the partner to be present. The requirements for witnesses vary by jurisdiction.

D. “An attorney will need to notarize this document for it to be valid.”Not all advance directives require notarization. The requirements vary by state or country, and some may only require witnesses.