Before answering this question, review the client's health information in the EHR. Identify which of the following assessments should concern the nurse. Select to highlight the four (4) correct answers.
2/9 1600, Nursing Assessment:
Neuro/Cognitive: Alert and oriented x 4. PERRLA.
Cardiovascular: normal rhythm, S1, S2
Respiratory: lung sounds clear; lung expansion is equal bilaterally; some upper airway congestion which the client reports as baseline
Gastrointestinal: abdomen firm and distended in suprapubic area, bowel sounds + in all quadrants
Genitourinary: Voiding small amounts every 6 hours. Denies urgency, frequency, hematuria, or leaking of urine. Has hesitancy. No dysuria. Bladder scan at 1620 noted 465 mL urine in bladder after 1610 void in toilet of 45 mL.
Musculoskeletal: moving arms and legs, grip strength strong in hands, left dorsiflexion strong, right leg slightly weaker
Pain: 2/10 “ache in the hip”