The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

A. Hydrocodone. This is an opioid analgesic appropriate for moderate to severe pain, such as a pain rating of 7/10. It is commonly used for acute pain management in cases like fractures and provides effective relief when non-opioids are insufficient.
B. Acetaminophen. While useful for mild to moderate pain, acetaminophen alone is likely inadequate for severe pain like that associated with a fracture rated 7/10.
C. Fentanyl. Fentanyl is a potent opioid used for severe or chronic pain, often in controlled settings such as surgery or cancer care. For an acute fracture, hydrocodone is typically preferred unless pain is extreme or uncontrolled.
D. Aspirin. Aspirin is primarily used for mild pain or anti-inflammatory purposes and is not appropriate as a first-line agent for severe pain. Additionally, it may increase the risk of bleeding, which is a consideration in trauma cases.

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.