Case Study, Chapter 8, Assessing General Health Status and Vital Signs

A 24-year-old client recovering from a motor vehicle accident which occurred 2 weeks ago

visits the health care facility today for a follow-up appointment. During the accident, the client

suffered a contusion to his head, lacerations to his face and neck, and a sprain to his lumbar area.

He was seen in the emergency department and discharged home the same day. A CT scan of his

head was taken at the time, which was negative. As the nurse begins the exam, the client appears

anxious. His speech is slurred, and she notices that his appearance is unkempt. His gait is steady

but slow. The client informs the nurse of a recent job loss and inability to cope with the job-

related stress after recovering from the accident.

He states he has been having headaches for a week. Pain scale reveals a 6 on a scale of

1 to 10. He informs her that he usually wakes up with a headache and takes the pain medication

given to him for his back injury suffered in the accident. He claims “The medication doesn’t

seem to help much.” He confesses to having taken twice the dose all this week.

VS: BP 138/80 mm Hg, HR 92 beats/min and bounding, RR 16 breaths/min, Pulse Ox 94%

(Learning Objectives: 4, 5, 7, 8)

Questions:

a. Based on the nurse’s assessment and the information obtained, what actions should
the nurse take?

b. What follow-up is indicated for this client?