A 78-year-old client has been hospitalized for the past week…
A 78-year-old client has been hospitalized for the past week for evacuation of a subdural hematoma after a fall. Immediately after surgery, the client was alert and oriented with right-sided hemiparesis. The client’s speech was slurred, but the client could communicate their needs without a problem. The client was continent of bowel and bladder most of the time and began rehabilitative therapies. On the third postoperative day, aspiration pneumonia was confirmed by x-ray, and the client was placed on IV antibiotic therapy. Today the nurse reviews the last entry in the Nurse’ Notes for an update on the client’s condition. NURSES’ NOTES DATE TIME NURSES’ NOTES April 3, 2025 0730 0730: Very drowsy this morning but can be aroused with gentle shaking. Remains oriented × 3. Does not readily respond when spoken to, but eventually answers in 1–2 words. No adventitious or diminished breath sounds. S1, S2 are present; no additional heart sounds. BS present × 4 and abdomen soft. Had 2 incontinent diarrheal stools during the night. Able to move all extremities but right arm continues to be weak. Skin intact; no reddened areas noted. Plan to send to PT and OT this morning. Temperature this morning has increased from 98°F (36.7°C) last evening to 100.2°F (37.9°C). The nurse reviews the notes and recognizes that the client’s findings that are of immediate concern include which of the following (Select All The Apply).