A client is admitted following a motor vehicle collision.
When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands.
The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward.
Which action should the nurse implement?

Choice A rationale:

The nurse should monitor the client for tachycardia as an adverse effect of beta blockers like metoprolol. Beta blockers work by reducing heart rate and blood pressure, so the presence of tachycardia would be unexpected and could indicate a potential adverse reaction to the medication.

Choice B rationale:

Hyperglycemia is not a common adverse effect of beta blockers like metoprolol. In fact, these medications can sometimes mask the symptoms of hypoglycemia, making it important for diabetic patients to closely monitor their blood glucose levels. However, hyperglycemia is not a typical side effect.

Choice C rationale:

Bronchospasm is not a common adverse effect of metoprolol. Beta blockers like metoprolol can cause bronchoconstriction in some individuals, but this effect is generally more prominent with non-selective beta blockers like propranolol. It is not a common adverse effect of metoprolol and would not be the primary concern when monitoring a patient on this medication.

Choice D rationale:

The nurse should monitor the client for hyperkalemia as an adverse effect of metoprolol. Beta blockers can inhibit the release of insulin from the pancreas, which can lead to elevated blood potassium levels (hyperkalemia). This is particularly important in patients with renal impairment, as they may have difficulty clearing excess potassium from the body.

The correct answer is B. "You seem quite frightened right now."

Choice A rationale:

This statement dismisses the client's feelings and may not provide the reassurance they need. It could also escalate the situation if the client feels misunderstood or ignored.

Choice B rationale:

This response acknowledges the client's emotions and validates their experience, which can help build trust and de-escalate the situation. It shows empathy and understanding, which are crucial in managing delusions.

Choice C rationale:

While this statement aims to reassure the client, it may not address their immediate emotional state. The client might not feel safe despite being told they are, so it might not be as effective in calming them down.

Choice D rationale:

This response could inadvertently reinforce the client's delusions by implying that their fears are valid and that the nurse should take action based on those delusions. It might also confuse the client further.