Exhibits

Click to highlight the findings that would indicate the client's condition has improved.

The client presents for his 30 day follow up appointment. The client reports not feeling dizzy when he gets up to ambulate. He reports his heart races at times when he goes to the bathroom. The client reports 1 episode of incontinence in the last 30 days. Gets up 1 to 2 times a night to void. Has noticed increased swelling of his testicles. Even with the penile implant, the client is unable to have penetrative intercourse with his partner. The client is experiencing body aches daily.

A. Ignoring the client's behavior (putting it on extinction) may escalate the situation, as clients with antisocial behavior often do not respond well to being ignored.

B. Informing him that the nurse is busy and will talk to him later sets clear boundaries while acknowledging his request. It helps manage his behavior without reinforcing negative actions.

C. Encouraging him to talk with another nurse may not address his immediate need for attention and could result in further disruptive behavior.

D. Introducing him to the newly admitted client may not be appropriate as it could disrupt the admission process and potentially intimidate the new client.

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C): While managing fever is important, it is not as immediate a priority as ensuring the client's breathing and hydration.

B. Start a peripheral IV: Establishing a peripheral IV line is crucial for administering medications and fluids. This is essential for the client's hydration and potential intravenous medication needs.

C. Chest x-ray: Although a chest x-ray is important for diagnosing the cause of the symptoms, it can be done after the client’s immediate needs for oxygen and IV access are addressed.

D. NPO: Keeping the client NPO is necessary, but it doesn't require immediate action compared to oxygenation and IV access.

E. Start oxygen 3 L/minute via nasal cannula: The client is experiencing difficulty breathing, so providing supplemental oxygen is a priority to ensure adequate oxygenation and alleviate respiratory distress.

F. Sputum culture: Obtaining a sputum culture is important for diagnosis, but it can wait until after the client is stabilized with oxygen and IV access.

G. Place the client on a cardiorespiratory monitor: Monitoring the client's cardiac and respiratory status is important, but ensuring oxygenation and IV access takes precedence.

H. Run 0.9% sodium chloride IV infusion at 150 mL/hour: While starting the IV infusion is important, it follows the establishment of the IV line and oxygen administration.