A nurse is caring for Susan (pronouns: she/her/hers), a 75-year-old female diagnosed with ovarian cancer 7 months ago after discovering a large inoperable tumor. After receiving a hand-off report from the previous shift registered nurse (RN), the nurse read through Susan’s electronic health record (EHR) and entered Susan’s room for shift assessment. The nurse collected the following data.

Recognizing Cues​

Select the information that requires further follow-up by the nurse.

Susan’s home medication list includes zolpidem, oxycodone, warfarin, and alprazolam. Her medical history indicates insomnia, an anxiety disorder, thrombophlebitis 3 years ago, and psoriasis. Susan’s lab results indicate a decreased WBC level. Her vital signs are: T 98.2 °F ( 36.8 °C ), HR 115, BP 110/62, RR 16. She clenches her teeth when her abdomen is palpated. When asked to describe her pain, she states that she has arthritis but otherwise is not in pain, describing the arthritis pain as "4" on a 0-10 pain scale. When asked if she is having other pain, she states that she does not and declines the offer of prescribed pain medication and other offers of pain relief interventions. Her husband, Don, is present in her room and states that she is in more pain than just arthritis. Susan reports that she has difficulty sleeping on occasion for which she takes zolpidem. She is answering the assessment questions and is oriented to person, place and time. Her affect is flatand she appears withdrawn. ​