A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?
Dietary salt restriction
Absence of symptoms
Addition of a new medication
A detailed plan of care
The Correct Answer is B
Rationale:
A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.
B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.
C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.
D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.
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Correct Answer is C
Explanation
Rationale:
A. Urine output of 120 mL in 4 hours is within acceptable limits, especially following anesthesia. Normal output can vary, but 30 mL/hr is often used as a guideline.
B. A systolic blood pressure that is only 12 mm Hg lower than preoperative levels may be concerning, but it does not necessarily require immediate reporting unless other symptoms are present.
C. Audible stridor is a sign of airway obstruction or severe respiratory distress and requires immediate medical attention. It should always be reported to the provider.
D. An occasional premature ventricular contraction (PVC) can be common postoperatively and may not necessitate reporting unless accompanied by significant symptoms or changes in hemodynamic status.
Correct Answer is A
Explanation
Rationale:
A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.
B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.
C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.
D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.