Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.

1. Poor personal hygiene

- Neglect: X

Rationale: Poor personal hygiene indicates neglect, as the caregiver is not providing adequate care for the client's basic needs.

2. Over sedation

- Physical abuse: X

Rationale: Over sedation is consistent with physical abuse because it involves administering medication to subdue the client, potentially to control or silence them.

3. Bruises in various stages of healing

- Physical abuse: X

Rationale: Bruises in various stages of healing are a sign of physical abuse, indicating that the client has been physically harmed multiple times over a period.

4. Depression or withdrawn behavior

- Mistreatment: X

Rationale: Depression or withdrawn behavior can be a result of mistreatment, which includes emotional and psychological abuse, leading to social isolation and emotional distress.

5. Untreated pressure injuries

- Neglect: X

Rationale: Untreated pressure injuries are a clear sign of neglect, as the caregiver is failing to provide necessary medical care to prevent and treat these injuries.

6. Leaving an older adult in a public space

- Mistreatment:

Rationale: Abandonment, which is a form of mistreatment, involves leaving the older adult in a public space without care or supervision.

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.