[Answered]: 0730 – The nurse enters the client’s room and…

0730 – The nurse enters the client’s room and introduces themselves to the client. The nurse notices that the client is sitting stiffly in bed and has a flat affect. The client’s partner is standing at the bedside looking at their phone. The nurse assesses the client’s pain. The client reports pain of 7 on a scale of 0 to 10 and states, “The pain is in my lower back, and it hurts to move. It feels like my muscle is cramping.” The client’s partner states, “I don’t think the pain is really that bad.” Vital signs are Temperature 37 ̊ C (98.6 ̊ F), Pulse 102/min, Respirations 22/min, BP 142/94 mm Hg, SpO2 99% on room air. On assessment, lungs are clear to auscultation, S1 and S2 noted, regular rhythm, skin warm and dry with bruises noted on right forearm, back, and face in various stages of healing. Which of the following assessment findings requires immediate follow-up? (Select all that apply.) Pulse Respirations Blood pressure Client’s affect Pain Muscle cramping Bruises Heart sounds