A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.

Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.

Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.

Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.

Choice A reason:

There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.

Choice B reason:

The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.

Choice C reason:

There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.

Choice D reason:

Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.

Choice E reason:

An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.

Condition F reason:

The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.

Condition G reason:

There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:

Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.

Condition I reason:

There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.

Parameter J reason:

Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.

Parameter K reason:

While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.

Parameter L reason:

Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.

Parameter M reason:

Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.

Parameter N reason:

Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.