A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

The correct answer is Choice A.

Choice A rationale:

Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. The committee can gather data, identify patterns, and provide insights into why staffing for weekend shifts is a challenge. This could involve surveying staff members, reviewing shift patterns, and analyzing workload and patient acuity data. By involving staff members in the process, the nurse manager can ensure that the perspectives and experiences of those directly affected by the staffing issues are taken into account. This approach aligns with the principles of shared governance and participatory management, which have been shown to improve staff satisfaction and retention.

Choice B rationale:

While providing support to staff members who are resistant to staffing changes is an important part of change management, it is not the first step that should be taken. Resistance to change is often a symptom of deeper issues, such as lack of trust, poor communication, or perceived lack of fairness or respect. By first forming a committee to investigate the staffing issues (Choice A), the nurse manager can gain a better understanding of these underlying issues and address them directly. This can help to reduce resistance when changes are implemented.

Choice C rationale:

Scheduling a staff meeting to present different options to staff members is a key part of the change process, but it should not be the first step. Before presenting options, it is important to fully understand the problem and consider various possible solutions. This involves investigating the current staffing issues (Choice A) and potentially developing and evaluating different scheduling options. Once this has been done, the options can be presented to staff members for feedback and discussion.

Choice D rationale:

Giving staff members advance written notice of staffing changes is a crucial part of transparent and respectful communication. However, it is not the first step in addressing staffing issues. Before any changes can be announced, the nurse manager needs to understand the problem (Choice A), consider possible solutions, and involve staff members in the decision-making process (Choice C). Once a decision has been made, it should be communicated clearly and promptly to all staff members.

Choice A rationale:

The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.

Choice B rationale:

Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.

Choice C rationale:

Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.

Choice D rationale:

Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.