Scenario

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client delivered vaginally three years ago under epidural anesthesia. She is now in active labor and has been admitted for monitoring and pain management.

Exhibits

Click to highlight the findings that indicate the client is progressing and ready for an epidural. Select three findings which indicate that this client is ready for epidural anesthesia.

Choice A rationale

Short-term memory loss is not typically associated with elder mistreatment. It may result from normal aging, neurological conditions like Alzheimer's disease, or other medical issues affecting cognitive function. It does not directly indicate mistreatment.

Choice B rationale

Malnutrition in the elderly can be a sign of neglect or mistreatment, where the individual may not receive adequate nutrition due to inadequate caregiving or intentional withholding of food. It can lead to severe health complications and indicates a lack of proper care.

Choice C rationale

Bilateral leg edema can result from various medical conditions, such as heart failure, chronic venous insufficiency, or renal disease. It is not a specific indicator of elder mistreatment and requires a thorough medical evaluation to determine the underlying cause.

Choice D rationale

Diminished breath sounds are typically related to respiratory conditions, such as pneumonia, chronic obstructive pulmonary disease (COPD), or pleural effusion. While they require medical attention, they do not directly indicate elder mistreatment.

Choice E rationale

Dark room lighting can suggest poor living conditions and inadequate care, potentially indicating neglect or mistreatment. Proper lighting is essential for the safety and well-being of elderly individuals, and its absence may reflect a lack of proper care and attention.

Choice F rationale

Poor hygiene is a common sign of neglect in elder mistreatment cases. It indicates that the individual may not receive assistance with personal care, leading to physical and emotional distress. Neglecting hygiene needs can result in infections and other health issues.

Choice G rationale

Pressure injuries, or bedsores, are often a result of prolonged immobility and inadequate repositioning, which can occur in cases of elder mistreatment or neglect. These injuries can lead to severe complications and are indicative of a lack of proper care and attention to the individual's needs.

Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.

Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.

Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.

Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.

Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.

Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.

Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.

Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.