Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

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 Depression or withdrawn behavior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Rationale: Depression or withdrawn behavior can be a result of mistreatment, which includes emotional and psychological abuse, leading to social isolation and emotional distress.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. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.

B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.

C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.

D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.