A nurse in an outpatient mental health center is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with paranoid personality disorder or borderline personality disorder. Each finding may support more than 1 personality disorder or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Rationale for correct choices:

• Apply oxygen via nasal cannula: The client is experiencing signs of decreased oxygenation (SpO₂ 92%), shallow respirations, and lethargy, which may indicate central nervous system depression from magnesium sulfate. Administering oxygen improves tissue perfusion and is a priority for maternal and fetal well-being.
• Calcium gluconate: Magnesium sulfate toxicity presents with depressed deep tendon reflexes, lethargy, and respiratory depression. Since the client's DTRs have decreased from 3+ to 1+ and respirations are now shallow, calcium gluconate should be prepared as the antidote to reverse toxicity promptly.

Rationale for incorrect choices:

• Reduce fluid intake: Although the client has reduced urine output and elevated creatinine and BUN levels, there is no indication of fluid overload. Reducing fluids does not address the immediate concern of hypoxia or magnesium toxicity, which are more urgent.
• Discontinue IV infusion: The IV is essential for delivering antihypertensive medications and magnesium sulfate. Discontinuing it would delay critical treatment and worsen the client’s condition. Adjustments, if needed, should follow provider orders after assessment, not be the nurse's initial independent action.
• Hydralazine: Hydralazine is appropriate for severe hypertension but is not the most urgent need when magnesium toxicity is suspected. Managing respiratory compromise and preparing the antidote takes precedence over blood pressure control in this case.
• Nifedipine: Nifedipine was already prescribed and may be administered for ongoing hypertension management. However, it is not used to treat magnesium sulfate toxicity and does not reverse respiratory depression. Thus, while important, it is not the immediate medication to prepare in this scenario.

Rationale:

A. Perform the Credé’s maneuver: This manual technique is used to assist bladder emptying in clients with urinary retention due to neurogenic bladder. It is not appropriate or necessary when continuous bladder irrigation is in place and the catheter is draining.

B. Maintain the irrigation solution rate: Pink-tinged urine is expected during the early postoperative period following TURP, indicating mild bleeding. There is no need to adjust the irrigation rate unless there are signs of obstruction or bright red bleeding with clots.

C. Replace the indwelling urinary catheter: Catheter replacement is only necessary if there is a blockage or malfunction. In this case, the system appears to be functioning correctly, and there’s no indication of obstruction.

D. Warm the irrigation solution: Warming the irrigation fluid is not required and does not affect hematuria. The solution should be at room temperature unless otherwise prescribed. Hematuria at this stage is managed by monitoring, not fluid temperature changes.