Patient Data Exhibits Which assessment factors require immediate nursing intervention based on the nurse’s assessment? Select all that apply)

Rationale for Correct Choices: Pain assessment: The client reports severe pain (8/10) that has persisted for 9 days without relief. Acute, uncontrolled pain can indicate a worsening gout flare or possible complication, requiring immediate nursing intervention to manage pain and prevent functional impairment. Temperature: The client’s oral temperature is 100.5°F (38.1°C), indicating a low-grade fever. Fever in the context of acute joint pain raises concern for infection, which requires prompt assessment and possible laboratory workup. Blood pressure: The client’s blood pressure is elevated at 151/87 mm Hg. While not immediately life-threatening, hypertension in combination with acute pain and fever increases cardiovascular risk and can exacerbate comorbidities. Prompt monitoring and intervention are necessary to prevent complications. Rationale for Incorrect Choices: Oxygen saturation: At 95% on room air, the client’s oxygenation is within acceptable limits and does not indicate an immediate threat to tissue perfusion. Edema: Mild (1+) bilateral lower extremity edema is chronic and consistent with underlying comorbidities, such as hypertension or possible venous insufficiency. It does not require immediate intervention in this acute scenario.