A female client is admitted with abdominal pain, possibly due to a gastric ulcer. Two days after admission, the client reports feeling nervous and tremulous. Further assessment reveals that the client's family is bringing a gin and tonic each night to help her relax. Which action(s) should the nurse take? Select all that apply.

A. "You didn't do anything wrong.” This statement is well-intended, but may minimize the parent’s emotional experience. It’s important to acknowledge the parent’s feelings rather than just reassuring them. This response does not invite further expression of their emotions.

B. "This must be a very difficult time for you." This response acknowledges the parent's emotional distress and validates their feelings, creating an opportunity for them to express their concerns. It provides emotional support and opens the door for further discussion.

C. "Is there any particular reason why you think this is your fault?" While it may be important to understand the parent’s concerns, this response is confrontational. It may inadvertently make the parent feel blamed, which could worsen their state instead of comfort.

D. "With surgery, your baby should have a full recovery." This response may give false hope and oversimplifies the complexities of myelomeningocele. Recovery outcomes depend on various factors. The focus should be on providing emotional support rather than making promises.

Rationale:

• Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
• Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
• Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
• Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.