Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)

When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child. Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.

Let's evaluate why the other options are incorrect:

B. Safety plan to keep in a purse at all times:

While a safety plan is essential for individuals experiencing domestic violence, providing a safety plan alone may not address the immediate danger the client is facing. It is crucial to prioritize the client's safety by connecting her with a women's shelter where she can receive comprehensive support.

C. Visit summary documenting the report of abuse:

While it is important to document any reports of abuse, providing a visit summary alone does not address the urgent need for the client's safety. Documentation can be helpful for future reference, but immediate action should be taken to ensure the client's well-being.

D. Paperwork needed to file a restraining order:

Filing a restraining order is a legal step that may be necessary in cases of domestic violence, but it should be pursued after ensuring the client's immediate safety. Providing paperwork alone does not address the client's immediate need for a safe environment. Connecting the client with a women's shelter is a more appropriate course of action to ensure her safety and well-being.

A) Incorrect- While understanding the frequency that a problem occurs can provide context to its significance and potential impact, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency alone does not ensure that the evidence collected will be directly applicable to the current situation.
B) Incorrect- Personal values are subjective and may influence an individual's perspective, but they are not the primary consideration when gathering evidence for evidence-based decision- making. Evidence-based practice aims to rely on objective and scientifically validated information rather than personal values, which can vary greatly among individuals.
C) Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.
D) Incorrect- While past experiences can offer insights, they are not the most important consideration for evidence-based decision-making. Relying solely on past experiences may not account for new developments, changing guidelines, or unique aspects of the current situation that were not present in previous encounters.