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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?

A.

Dietary salt restriction

B.

Absence of symptoms

C.

Addition of a new medication

D.

A detailed plan of care

Answer and Explanation

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 B

Explanation

Rationale:

A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.

B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.

C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.

D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.

Correct Answer is B

Explanation

Rationale:

A. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.

B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.

C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.

D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.

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