A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Which of the following actions should the nurse plan to take?

The correct answer is choice c. Swelling of the face.

Choice A rationale:

Urinary frequency is a common symptom during pregnancy, especially in the first and third trimesters, due to hormonal changes and the growing uterus pressing on the bladder. It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination, which could indicate a urinary tract infection.

Choice B rationale:

Bleeding gums are also common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding. This condition, known as pregnancy gingivitis, is usually not serious but should be managed with good oral hygiene.

Choice C rationale:

Swelling of the face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs, often the kidneys. Preeclampsia typically occurs after 20 weeks of gestation but can develop earlier. It requires immediate medical attention to prevent complications for both the mother and the baby.

Choice D rationale:

Faintness upon rising, or orthostatic hypotension, is relatively common during pregnancy due to changes in blood circulation. It can usually be managed by rising slowly from a sitting or lying position. However, if fainting is frequent or severe, it should be discussed with a healthcare provider to rule out other underlying conditions.

The correct answer is Choice B: Speak in a normal voice at a natural pace.

Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.

Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.

Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.

Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.