Exhibits

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0900

Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking

Rationale

A. Blood cultures are typically obtained to identify the causative organism of the liver abscess and to monitor the effectiveness of antimicrobial therapy. While repeat blood cultures may be considered if there is concern for ongoing infection or antimicrobial resistance, they may not be the immediate priority in the context of new-onset jaundice.

B. Jaundice indicates possible liver dysfunction, which can occur due to various reasons including progression of the liver abscess, obstruction of the bile ducts, or drug-induced liver injury from antimicrobial therapy. Evaluating liver function tests (such as serum bilirubin, liver enzymes) is essential to assess the extent of liver damage and guide further management.

C. Increasing protein intake is generally not indicated as the immediate response to jaundice. While adequate nutrition is important, specific dietary adjustments should be based on comprehensive assessment findings and medical recommendations.

D. Emergency transport to an inpatient facility may be necessary if the client shows signs of severe complications such as hemodynamic instability, worsening symptoms, or acute liver failure. However, this decision should be based on a thorough assessment of the client's condition and the availability of resources at the community clinic.

Rationale

A This statement is incorrect for diabetes management. People with diabetes should avoid soaking their feet in hot water, as it can lead to burns and skin damage, which is particularly risky due to potential nerve damage (neuropathy) and poor circulation common in diabetes.

B. This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

C. Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

D. While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection