Assignment Task:
NEXT-GENERATION NCLEX® QUESTION
Ms. Parra, 68 years old, arrives in the emergency department via ambulance. The report from emergency services personnel indicates she fell in her home with loss of consciousness. The nurse obtains her history. The client states she slipped in the bathroom while getting up to urinate during the night; the need to urinate was urgent and she feels she rushed more than usual. When she fell, she hit her head on the sink and passed out. She was wearing her medical alert watch; it notified emergency services she had fallen. Ms. Parra's medical history includes hypertension and osteoarthritis in her knees. Her medications include atenolol 50 mg daily, meloxicam 7.5 mg daily, and acetaminophen as needed. Although she had never fallen before, her daughter bought her the medical alert watch when she noticed how stiff Ms. Parra became after short periods of inactivity. Vital signs include a blood pressure of 100/68 mmHg, heart rate of 58 beats per minute, respirations of 16 breaths per minute, temperature of 99.5°F, and oxygen saturation of 98% on room air. Results of laboratory work include:
- White blood cell count: 12.5?×?103 cells/mm3
- Hemoglobin and hematocrit: 16 g/dL and 45%
- Platelet count: 100,000 cells/mm3
- Blood urea nitrogen/creatinine: 23 mg/dL and 1.2 mg/dL
- Sodium: 142 mEq/L
- Glucose: 100 mg/dL
- Urinalysis: Urine is amber and clear, pH 7.0, nitrite negative and leukocyte esterase +, blood 5/hpf, WBC 10/hpf, and bacteria 100,000 CFUs/mL.
Highlight the assessment data above that require follow-up by the nurse. The answer should read like a nursing report. Please Cite and provide references.