A young client is brought into the emergency department by a…

A young client is brought into the emergency department by a friend who says the client was “beat up” at school. The client has bruising and lacerations to the face and torso. The client is reluctant to provide the names of parents or a home address. Which information can the nurse safely assume about this client?

A nurse in an emergency department (ED) is admitting a clien…

A nurse in an emergency department (ED) is admitting a client.   Vital Signs     1200: Temperature 38.6° C (101.5° F) Heart rate 109/min Respiratory rate 28/min Blood pressure 106/54 mm Hg Oxygen saturation 94% on room air   Nurses’ Notes   1200: Client presents to ED with report of shortness of breath for 2 days, with headache, chills, fever, sore throat, and cough. States they went to a music concert recently “and probably picked up some kind of virus.” Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.  Client’s face is flushed, sinus tachycardia, rate of 109/min, S1S2 heart sounds heard on auscultation. Pulses palpable.  Breath sounds with crackles to right lower lobe, tachypnea, rate of 28/min. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are “more comfortable sitting up.” Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States “no appetite since I’ve been sick.” Reports decreased urination over past 24 hr. “Haven’t been drinking as much water as I should because my throat hurts.” Client reports they have not had a pneumococcal vaccine and does not get annual influenza vaccinations. States, “I just hate needles.”   Medical History 1215: 70 years of age No significant medical history other than primary concern Well nourished   Home Medications: Daily multi-vitamin Vitamin D   Social History: Lives alone, partner died 5 years ago Drinks 1 to 2 glasses of red wine daily Has never smoked Walks 2 to 3 miles 6 days/week   Diagnostic Results 1230: Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia Question:  Using the data provided, select the findings that in the client’s medical record that place them at risk for pneumonia. (Select all that apply.)