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A 45-year-old client, recovering from an ischemic stroke, is nearing discharge from a rehabilitation facility. While demonstrating significant physical gains in therapy, the client expresses profound anxiety about returning to their single-story home alone.
The client confides in the nurse, stating, "I'm terrified I'll fall again and no one will know. I don't want strangers in my home, but I also don't know how I'll manage simple things like bathing or cooking without help." The client's adult children reside out of state and can offer only limited remote support. The nurse identifies potential needs for home health services and assistive devices, but the client quickly changes the subject whenever referrals are broached, reiterating a desire for complete independence and privacy.
Which action should the nurse prioritize FIRST?
The client's expressed fears regarding home safety and their underlying reluctance to discuss or accept support services present a significant barrier to effective discharge planning. Prioritizing a therapeutic conversation to explore these specific concerns allows the nurse to understand the client's perspective, identify the root causes of resistance, and address psychological barriers to accepting necessary care. This foundational step is critical for promoting client autonomy and ensuring a safe and successful transition to home.
Without first addressing the client's resistance, initiating referrals or providing general education is unlikely to be effective, as the client may reject these services. Understanding the client's specific anxieties and values will enable the nurse to tailor information and future referrals more effectively, aligning with client-centered care principles and ultimately enhancing safety upon discharge.
A nurse on a medical-surgical unit is conducting a routine developmental assessment for a 4-month-old infant admitted for observation following a febrile seizure, now afebrile and stable. The nurse reviews the infant's chart, noting a full-term birth with no reported complications and appropriate weight gain since discharge.
During the assessment, the infant is awake and alert, tracking the nurse's movements with their eyes. The nurse observes the infant's reflexes, muscle tone, and interaction with a toy. The parents express slight concern about the infant's general 'quietness' compared to an older sibling at the same age.
Which of the following assessment findings would be the most concerning to the nurse?
The persistence of the Moro reflex beyond 3-4 months is a significant neurological red flag. While this primitive reflex can occasionally be present until 6 months, its strong persistence at 4 months, when it should be diminishing, indicates a potential delay in neurological maturation or an underlying neurological issue. This deviation from expected developmental progression (aging process) warrants immediate further investigation as it may compromise the infant's safety and future developmental trajectory.
In contrast, an infant laughing aloud when tickled demonstrates appropriate social-emotional and communication development. The ability to hold their head steady when supported in a sitting position signifies expected gross motor development. Beginning to reach for objects, even with occasional misses, indicates normal fine motor and visual-motor integration skills. These three findings are all considered appropriate and healthy milestones for a 4-month-old infant.
An 82-year-old client, Mrs. Albright, is admitted to the pediatric unit for observation after a fall she sustained while visiting her critically ill 6-year-old grandchild. She is medically stable, but appears disoriented and agitated by the unfamiliar environment, the presence of young children, and the constant activity. Her primary caregiver daughter lives in a different state and is currently traveling to the hospital.
Mrs. Albright expresses feelings of loneliness and anxiety, stating, "I just wish my daughter was here. I don't know any of these people, and it's so noisy here." The nursing staff has noted her refusing meals and struggling to sleep due to the unfamiliar surroundings.
Which teaching instruction should the nurse prioritize to best address Mrs. Albright's immediate psychosocial needs?
The client is an 82-year-old experiencing significant psychosocial distress, including disorientation, anxiety, and loneliness, exacerbated by an unfamiliar and inappropriate clinical environment (pediatric unit) and the absence of her primary support system. This distress is manifesting as refusal of meals and difficulty sleeping, impacting her physiological and psychological well-being. According to Maslow's Hierarchy of Needs, psychological safety and belonging are immediate priorities after basic physiological needs. Actively arranging an immediate consultation with a hospital social worker or chaplain provides a direct, professional psychosocial support system to the client when her primary support is unavailable. This intervention directly addresses her stated feelings of loneliness and anxiety, offering a new connection and resource. This action demonstrates proactive nursing care by establishing an immediate alternative support system, which is crucial for her overall safety and well-being in this challenging situation.
Other options, while well-intentioned, do not provide an immediate, tangible support system or adequately address the depth of her psychosocial distress. Reassurance alone does not provide a new coping mechanism or connection. Teaching about practical resources like the intercom or visiting hours, while important, does not address her profound emotional state or the absence of a meaningful connection. Encouraging focus on the grandchild's recovery shifts the burden to the client rather than providing support to her and may invalidate her own distress.
A 35-year-old client, recently started on lisinopril 10 mg daily for newly diagnosed hypertension, presents to the outpatient clinic for a follow-up visit. The client reports generally feeling well, but mentions a "strange swelling" that started yesterday.
During the physical assessment, the nurse notes several key findings. The client's blood pressure is 128/78 mmHg, heart rate 72 bpm, respiratory rate 16 bpm, and oxygen saturation 99% on room air. The client denies any difficulty breathing or chest pain.
Which of the following assessment findings warrants the nurse's immediate and most serious concern?
The swelling of the lips, tongue, and soft palate, along with a subjective sensation of throat tightness, are classic signs of angioedema, a rare but life-threatening adverse effect of ACE inhibitors like lisinopril. Angioedema can rapidly progress to severe airway obstruction, making it an emergent situation requiring immediate intervention to protect the client's airway and prevent respiratory arrest. This finding directly impacts the client's airway, falling under the highest priority of the ABCs (Airway, Breathing, Circulation).
While a persistent cough is a common and expected side effect of ACE inhibitors, and orthostatic hypotension can occur, these do not pose the same immediate threat to life as angioedema. A serum potassium level of 5.4 mEq/L indicates mild hyperkalemia, which warrants further assessment and intervention but is not as immediately critical as a compromised airway. The nurse's priority is always to ensure airway patency, breathing, and circulation.
A 3-year-old child with a known history of severe, progressive muscular dystrophy is brought to the emergency department by their parents. The child has a "Do Not Resuscitate" (DNR) order in place as part of their established palliative care plan. The parents report the child became acutely lethargic and stopped responding to their voices an hour ago. Upon assessment, the child's breathing is agonal, peripheral pulses are weak and thready, and pupils are fixed and dilated. The parents are huddled by the bedside, tearfully stroking their child's hair and whispering prayers, asking, "What happens now? Is there any pain?"
The ED charge nurse has an experienced Registered Nurse (RN), a Licensed Practical Nurse (LPN), and Unlicensed Assistive Personnel (UAP) available. Other patients in the department are stable but require ongoing monitoring.
Considering the family's immediate needs and the child's condition, which assignment represents the most appropriate delegation of care by the charge nurse?
The experienced Registered Nurse's continuous presence at the bedside for a dying child and grieving parents is paramount. This assignment addresses Maslow's physiological needs (comfort through assessment and advocacy) and higher-level needs (love/belonging and self-esteem for the family) by providing immediate, skilled psychosocial support (active listening, anticipatory guidance regarding the dying process). In this highly sensitive, emergent end-of-life situation, the RN's expert assessment skills are crucial for identifying subtle, non-verbal signs of discomfort in a non-communicative 3-year-old, ensuring prompt advocacy for comfort medication administration. This complex, holistic role integrates advanced assessment, communication, and emotional support, which are exclusive to the scope and expertise of an experienced Registered Nurse.
Other options, while containing some valuable tasks, either fall outside the immediate priority for the most experienced clinician (e.g., contacting other teams), are inappropriate for the scope of practice (e.g., LPN monitoring SpO2 in an actively dying DNR patient, which provides little actionable data and can detract from comfort focus), or represent basic comfort measures that do not address the critical, complex psychosocial and assessment needs requiring a licensed nurse's direct and continuous attention (e.g., UAP tasks).
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