A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

 

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.

A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.

B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.

C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.

D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.