Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.

Choice A rationale:

Nosocomial transmission in the medical area. Rationale: Nosocomial transmission refers to infections that are acquired in healthcare settings. While it's essential for healthcare professionals to be aware of this risk, the client's presentation of diarrhea in a hurricane disaster area is more likely due to environmental factors rather than hospital-acquired infection.

Choice B rationale:

Food contamination from floodwaters. Rationale: In the aftermath of a hurricane, floodwaters can carry contaminants and pathogens, leading to food contamination. This is a significant concern, and the nurse should educate the client about the potential risks associated with consuming food exposed to floodwaters. However, the primary source of contamination for diarrhea is typically waterborne pathogens, which is addressed in choice C.

Choice C rationale:

Drinking water contaminated by sewage. Rationale: During natural disasters like hurricanes, sewage systems can become compromised, leading to the contamination of drinking water sources. This contamination poses a significant risk for diarrheal illnesses, as sewage often contains harmful pathogens. Therefore, the nurse should consider this as the most probable source of the client's exposure.

Choice D rationale:

Close living quarters at evacuation centers. Rationale: Close living quarters in evacuation centers can contribute to the spread of infectious diseases, including diarrheal illnesses. However, in this scenario, the client's chief complaint is diarrhea, and the nurse should prioritize investigating potential sources of waterborne contamination, as this aligns more closely with the client's symptoms.