The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A) The client's meal tray includes ice cream with fresh fruit: Fresh fruit poses a risk to a neutropenic client because it may harbor harmful bacteria or fungi, which could lead to an infection. Neutropenic clients have a weakened immune system and are more vulnerable to infections, so it is essential to avoid raw or unwashed fruits that can carry harmful pathogens.

B) The client is assigned to a room with negative airflow: A room with negative airflow is a precautionary measure used to prevent the spread of airborne pathogens, particularly for clients with compromised immune systems. This would help reduce the risk of infection by keeping potentially harmful microorganisms from circulating into the room.

C) The client has artificial flowers in the room: While artificial flowers may not pose an immediate risk for infection, they can accumulate dust and other particles that may contribute to a less clean environment. However, they are not as significant a risk factor as the presence of fresh fruits, which can carry live microorganisms capable of causing infections in neutropenic patients.

D) The client's meal tray contains hard boiled eggs: Hard boiled eggs are generally considered safe for neutropenic clients as long as they are properly cooked and stored. Eggs are not a known source of infection in this context, especially when they are cooked and handled properly.

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.