Exhibits

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

• Fatigue
• Generalized weakness
• Muscle cramps
• Tingling sensation in her arms and legs
• Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

• Blood Pressure: 146/82 mmHg
• Heart Rate: 114 bpm
• Respiratory Rate: 18 bpm
• SpO₂: 98% on room air
• Temperature: 98.2 °F (36.8 °C) orally

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."

Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.

Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.

Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.

Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD

Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.