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Difficulty: HardHigh Risk Behaviors

An adult client arrives at an urgent care clinic presenting with a firm, erythematous, and tender area on the jawline. During the initial data collection, the client confides to the practical nurse (PN), "I have been doing my own cosmetic filler injections at home with products I ordered online." Which action should the PN take first?

  1. A
    Request that the client describe their home sterilization technique to identify potential sources of contamination.
  2. B
    Perform a comprehensive health risk assessment to evaluate the client's understanding of unregulated medical devices.
  3. Obtain a full set of vital signs and promptly report the localized tissue assessment to the healthcare provider.Answer
  4. D
    Reassure the client that the facial swelling will likely subside rapidly once an appropriate antibiotic is prescribed.

Answer

Obtain a full set of vital signs and promptly report the localized tissue assessment to the healthcare provider.
The correct action addresses the immediate physiological threat while remaining strictly within the practical nurse's scope of practice. An erythematous, tender area resulting from unsterile, unregulated home injections strongly indicates an acute infection. The PN must prioritize physiological safety by gathering a complete set of vital signs (to assess for systemic indicators like fever or tachycardia) and promptly notifying the healthcare provider to facilitate medical intervention.

Step-by-Step Solution

1
Analyze the client's presentation and disclosure.
The client has engaged in a high-risk behavior (unregulated home injections) and now presents with clinical signs of a localized infection.
Identifying the primary clinical problem and associated risks is the first step in clinical decision-making.
2
Determine the priority of care.
Physiological safety is the immediate priority, as the localized infection poses a risk for systemic involvement such as sepsis.
Prioritization frameworks dictate that physiological threats take precedence over teaching, psychological assessment, or secondary investigation.
3
Select the appropriate action within the PN scope of practice.
The PN should collect objective physiological data (vital signs) and report the findings to the supervising provider.
Comprehensive assessments are outside the PN scope, and offering false reassurance is non-therapeutic.

Key Concept

Prioritizing physiological data collection and reporting in clients presenting with complications from high-risk behaviors.
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Topics

High Risk Behaviors

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