Kaylee (pronouns: she/her/hers), a 19-year-old college student who is living away from home for the first time, has been feeling tired and having trouble focusing for the last few weeks and goes to the campus clinic to see the nurse. Below is the nurse's notes after the initial assessment.
Date/Time NURSE'S NOTES
10/10/XX
09:30
19-year-old female seeking treatment for fatigueand trouble focusing times 3 weeks. Has lost 13 pounds in the last month (7% of body weight), body mass index (BMI 22); recently began eating vegan (no animal-based foods) and eats mostly salads and fresh fruit; BP 118/68, HR 66 and regular, RR 16 at rest, T 101.1 °F (38.4 °C); client shares that she has had a sinus infection for about a week; sleeping more; has not exercised in "a long time"; has trouble focusing during class and when studying.
Analyzing Cues
The nurse is reviewing the results of Kaylee's laboratory tests (see below). For each lab value, select if the nurse should contact the provider immediately, within 24 hours, or no contact is needed at this time.
Serum albumin 2.9 g/dL (3.5-5 g/dL)
Hemoglobin 8 g/dL (12.2-15.1 g/dL Female)
White blood cells 17,500 µL (4,000-10,000 μL)
Prealbumin 9 mg/dL (16-40 mg/dL)
Red blood cells 4.2 x106/ µL (4.2-5.4 x106/ µL Female)
Potassium 3.5 mEq/L (3.5-5 mEq/L)
Contact Immediately
Contact Within 24-Hours
Do Not Contact