The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?

Choice A reason:

Requesting that the man get up and leave disregards the client's autonomy and right to privacy. It can be seen as intrusive and disrespectful, potentially causing embarrassment and distress to the client. In a long-term care facility, residents have the right to engage in consensual relationships. By asking the man to leave, the nurse would be infringing on the client's personal rights and freedoms. This action could also damage the trust and rapport between the nurse and the client, making future interactions more difficult.

Choice B reason:

Reporting the incident to the family breaches the client's confidentiality and privacy. The client has the right to engage in consensual relationships without family interference unless there are concerns about safety or capacity. Involving the family in such personal matters without the client's consent can lead to unnecessary conflict and distress. It is important for healthcare providers to respect the client's autonomy and confidentiality, ensuring that their personal choices are honored and protected.

Choice C reason:

Exiting the room and quietly closing the door respects the client's privacy and autonomy. It acknowledges their right to intimate relationships and maintains their dignity. This action demonstrates respect for the client's personal space and choices, fostering a supportive and respectful environment. By quietly exiting, the nurse avoids causing embarrassment or discomfort, allowing the client to maintain their dignity and privacy. This approach aligns with ethical principles in healthcare, emphasizing respect for the client's autonomy and personal rights.

Choice D reason:

Asking when the nurse should return interrupts the client's private moment. It can be handled more discreetly by returning later without disturbing them. This action, while less intrusive than asking the man to leave, still fails to fully respect the client's privacy. By asking when to return, the nurse is drawing attention to the situation, which can cause embarrassment and discomfort. A more respectful approach would be to quietly exit and return at a later time, ensuring that the client's privacy is maintained.

To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:

• Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
• Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
• Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
• Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
• Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
• Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.

Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.