Nursing Care Planning for a Post-Operative Client

Nichole "Nick" Blackburn is a 53-year-old Caucasian client. The client was assigned female at birth and identifies as male. The client prefers to be called "Nick" and uses he/his/him pronouns. The client was admitted 2 days ago following a bicycle accident. The client fractured his left fibula and tibia. An open reduction/internal fixation on the left leg was performed yesterday. The client was kept overnight for observation and pain control. The client has a patient-controlled analgesia pump (PCA) and has been instructed on how to use it. Past medical history includes hypertension, depression, total hysterectomy (1 year prior), and double mastectomy (1 year prior). Home medications include the following: bupropion (Wellbutrin) 150 mg PO daily, spironolactone (Aldactone) 200 mg PO daily, lisinopril (Zestril) 10 mg PO daily. Client is alert and oriented to time, place, and person. Client is well-developed and appears well nourished. S1 and S2 heart sounds noted. Lung sounds are clear in all lung fields with no adventitious sounds noted. Abdomen soft and non-tender. Soft cast noted to left leg. Capillary refill in left toes is less than 2 seconds. No swelling noted above or below cast. Client instructed to call for ambulatory assistance when walking. Pain reported in the left leg rated as a 10 on a 0 to 10 pain scale. Multiple lacerations and bruising noted bilateral arms and legs. A 2-inch laceration to the chin with sutures noted. All wounds are clean with no drainage and no active bleeding. Client is inquiring about discharge and where to get crutches. The client verbalizes concerns about falling due to living in a building with stairs and no elevator. Vital signs are as follows: temperature 36.8° C (98.3° F), heart rate 95/min, respirations 22/min, blood pressure 108/78 mm Hg, oxygen saturation 100% on room air. Which of the following concerns should the nurse plan to address? (Select all that apply.)