Question

Urinary Elimination LPN Unfolding Case Study A 22-year-old male was admitted to a cardiac stepdown unit for right upper quadrant pain, nausea and vomiting. The client states their pain is a 9 out of 10 to RUQ and RLQ and radiates to his right flank area. The client stated "I'm in so much pain, I took all the acetaminophen extra strength tablets i could find before I came to the Emergency Department". The client has a medical history of kidney stones, bipolar depression, and primary hypertension. Their surgical history reveals a tonsillectomy two years ago. VS are BP 160/100, P 90, R 20, T 99.2 F, and O2 sat is 98%. The telemetry technician states the ECG monitor shows a normal sinus rhythm with a rate of 92. Current home medications are acetaminophen 500 mg 1 to 2 tablets PRN pain, sertraline 100 mg one PO daily, quetiapine 200 mg one POq HS and lisinopril 20 mg one PO daily. HCP orders home medications, a CT scan of the abdomen and hydrocodone 5 mg/ acetaminophen 325 mg one or two tablets PO every 6 hours PRN for moderate pain and morphine 2-4 mg IP q 2 hours PRN for severe pain. Highlight the assessment findings that require immediate follow-up by the nurse.

Answer 1

The assessment findings that require immediate follow-up by the nurse include the client's high blood pressure, severe pain, and history of kidney stones.

Step-by-step explanation:

The assessment findings that require immediate follow-up by the nurse include the client's high blood pressure (160/100 mmHg), as this indicates hypertension, which can be a risk factor for cardiovascular events. Additionally, the client's severe pain (rated at 9 out of 10) and use of a large amount of acetaminophen tablets may indicate a possible overdose and warrant immediate attention. Lastly, the client's history of kidney stones and the presence of blood in their urine could suggest kidney complications that need to be addressed.