The nurse in the long-term care facility is caring for a 19-year-old client. The nurse is contributing to the client's plan of care. Based on the following Nurses' Notes and History and Laboratory Results, specify whether each potential nursing intervention is indicated or not indicated for the client.
Nurses' Notes:
1100: Client has piloerection on the arms and legs and diaphoresis on the forehead. Client is wearing new, low-top athletic shoes purchased by the client's parents instead of prescribed foot splints. During abdominal palpation, a semi-firm mass is noted in the left lower quadrant (LLQ). Bladder is nonpalpable.
1115: Intermittent urethral catheterization was performed, and 400 mL of clear yellow urine obtained. Client has facial flushing and foul-smelling liquid stool leaking from the anus. Semi-firm mass is still present in the LLQ of the abdomen.
1130: Client reports a headache rated 10/10 on the Numerical Rating Scale and blurred vision.
Potential Nursing Interventions:
A. Place the client in the left lateral position.
a. Indicated
b. Not Indicated
B. Remove the client's low-top athletic shoes.
a. Indicated
b. Not Indicated
C. Inform the client that the Crede method will be performed.
a. Indicated
b. Not Indicated
D. Request a prescription for an over-the-counter (OTC) laxative.
a. Indicated
b. Not Indicated
Note: Each row must have 1 response option selected.