Problem:
Initial Nursing Assessment:
The nurse reviews the information received in the report and enters the client's room to perform a physical assessment. Upon assessment, the client is confused and disoriented. Pupils are equal, round, reactive to light, and accommodation. Lung sounds are equal bilaterally, with no adventitious lung sounds present. $152 heart tones noted. All pulses palpable. Client occasionally moans and grimaces but is unable to rate pain on a numeric pain scale or FACES pain scale. Abdomen is soft and nontender. Hypoactive bowel sounds noted in all four quadrants. Client is lying in supine position. Right leg in traction. Sitter in the room with client. Call light within reach. Which of the following concerns should the nurse address while providing client care? (Select all that apply.) Physiological: Comfort • Physiological: Nutrition • Physiological: Elimination I Physiological: Mobility • Physiological: Tissue Integrity # Health Promotion: Client Education I Psychosocial: Cognition • Physiological: Infection